Patient Forms

Please fill out online version or print and fill out form and fax to: (402) 465-9011

New Patient Registration (online version | printable version)
New patient to complete

HIPAA Form (online version | printable version)
Complete only if not previously signed or you wish to change

Insurance Procedures (online version | printable version)
New patient to complete

Patient History (online version | printable version)
DO NOT COMPLETE IF NURSE CALLS YOU FOR A PROCEDURE AS NURSE WILL COMPLETE. If for a consult and not seen in 3 years, please complete.

For your first visit please complete all 4 forms.
Our website provides the paperwork needed so that we may open a medical chart for you. Please complete your information on line.  If you are unable to do so, please print and complete the forms and either fax them to 402-465-9011, mail them, or bring them to the clinic prior to your appointment so that your medical record will be ready for your visit.

When you arrive for your appointment please bring your insurance card, a referral (if required) from your primary care physician, and additional test results or pertinent medical records. We also suggest that you arrive 20 minutes early for your scheduled office appointment and 30 minutes early for your procedure at Lincoln Endoscopy Center.

For follow-up appointments you do not need to complete any additional forms.

For procedures or have not been seen in 3 years as an existing patient, please complete the history and physical form.
If the nurse has called you and taken the information, do not complete the form on line.

All of this will hopefully lead to a prompt and stress free first visit with us. We look forward to providing you and your family with the highest quality medical care in a professional setting. If you have additional questions call 402-465-4545.