Intake Forms

Complete Your Forms Before Your Visit

Download and fill out your patient forms in advance to streamline your check-in process. This helps us provide you with efficient, personalized care right from the start.

Intake Forms

Authorization to Disclose Healthcare Information

Download

Patient Registration Form

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Consent to Treat a Minor

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Questions? We Have Answers.

Yes, we have a provider on call for urgent needs after hours. If you have an emergency, please call 911. Prescriptions will only be filled during normal business hours.

Yes, we do cover weight loss medications, however, please check with your insurance for coverage before making an appointment.

We DO NOT participate in any CHI narrow network plans. Please contact your insurance company to verify.

Aetna Healthcare
Aetna (Broad Network), First Health (except “First Health Professionals Only”), Aetna High Performance Network (Nebraska Health Network), Aetna Signature Administrators

Ambetter
Ambetter (through Marketplace)

Blue Cross Blue Shield of Nebraska
BCBSNE Federal Plan, BCBSNE Network Blue, BSCSNE BlueCard HMO (only with suitcase logo), BSCSNE BlueCard PPO, BSCSNE Select Blue, BSCSNE Student Blue

Century Health Solutions
Century Health Solutions

Humana
Humana Choice Care, Humana One PPO

Medica
Medica Elevate, Medica Insure, Medica Commercial, Kansas

Medicaid Nebraska
UnitedHealthcare Community Plan

Medicare
Medicare Part A & B

Medicare Advantage
Aetna Medicare Premier Advantra (PPO), Aetna Medicare Elite Advantra (PPO), Aetna Medicare Premium Advantra (PPO), BCBSNE Medicare Advantage Core (HMO), BCBSNE Medicare Advantage Choice (HMO-POS), Humana Gold (HMO) Medicare Advantage, HumanaChoice (PPO) Medicare Advantage, Medica Advantage Solution, Medica Prime Solution Total Cost Medicare Advantage, UnitedHealthcare Medicare Advantage, Wellcare by Nebraska Total Care Medicare Advantage

Midlands Choice
Commercial plans

MultiPlan
MultiPlan (Does not include PHCS)

Tricare West
Tricare West Active Duty, Tricare West for Life, Tricare West Prime

UnitedHealthcare
Golden Rule, Medica, NexusACO, Optum VA Community Care Network (CCN), Oxford Health, United Medical Resources, UnitedHealthcare

Wellmark of Iowa
Wellmark Blue HMO

Other
Nebraska Furniture Mart Employee Plan Tier 1

We do not offer telephone or virtual appointments at this time.

No. We defer to hospitalists programs in our local community.

Still have questions?

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