Welcome to Omaha Health Clinic
14440 "F" St. Suite 121 Omaha, NE 68137
Phone: 402-933-4450
Fax: 402-933-4490

Please take a few minutes to answer the questions on this form, so we can better assist you with your health needs.

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Please type your full name.

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IN CASE OF EMERGENCY, WHOM SHOULD WE CONTACT?
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PROTECTED HEALTH INFORMATION MAY BE RELEASED TO:
(personal information can be shared with)
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Please list all the names of the medications with dosage and how often medication is taken:
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FINANCIAL POLICY:

The following is a statement of our Financial Policy. All patients must accept our Financial Policy before receiving treatment.

METHOD OF PAYMENT: We accept CASH, CHECK, DEBIT & OR CREDIT CARDS. Payment plans may be arranged on an individual basis with our billing manager.

REGARDING YOUR INSURANCE: As a courtesy to you, we will submit medical claims to your insurance company. Any balance after the processing of our claim by your carrier will be your responsibility. Your insurance policy is a contract between you and your insurance company. You are responsible for verifying if providers are in network with your insurance company. We cannot bill your insurance company unless you give us your complete insurance information. It is your responsibility to know your insurance benefits as it may not cover all the services provided to you.

DEFINITIONS:

CO-PAYMENT: A fixed dollar amount set by your insurance contract that is required to be paid at the time of an office visit. This amount is usually between $15 and $50 and is usually noted on your insurance card. All co-pays are due at registration for your appointment.

DEDUCTIBLE: An annual dollar amount established by your insurance plan that is deducted from insurance benefits. This amount is your obligation.

CO-INSURANCE: A percent set by your insurance plan that is deducted from your insurance benefits. If you do not have a co-pay amount, then a co-insurance amount of 20% will be charged to you at the time of your visit. (Medicare/Medicaid patients will not be charged at the time of service.) Medicare patients will be billed after Medicare pays.

SELF-PAY: A patient that does not have any valid health insurance. You will be asked to pay for services at the time of your appointment.

MVA-policy: We will not file your insurance claim to your motor vehicle insurance. We will collect your personal insurance information at the time of service to file a claim if payment from your MVA is not received within 60 days of service. If insurance has not paid this claim within 90 days, the amount due will become the patient’s responsibility.

PERSONAL INJURY (LIABILITY): We require a financial arrangement be established for payment in full at the time of service for personal injury cases. We will file a claim with your personal insurance if you wish, but you will still be required to do the above financial arrangements.

WORK RELATED INJURIES: We will file Workers Compensation claims with your employer’s WOrkers Compensation Insurance Carrier. Written or telephone authorization is required from your employer and/or insurance company prior to treatment. If prior authorization is not obtained, you are responsible for full payment at the time of service. If your company;s Workers Compensation carrier has not paid your account in full within 90 days of your date of service, the balance will be transferred to your account and it is your responsibility to pay in full by the statement due date.

RETURNED CHECK: A $35 service fee will be added to all checks returned for insufficient funds. If your check is returned, you will be required to pre-pay in full by cash or credit card for additional services.

COLLECTION ACCOUNTS: All services after an account has been given to a collection agency will be on CASH ONLY basis. All co-pays and deductibles will be collected at the time of service. If you are unable to comply your appointment will be rescheduled.

I acknowledge that I was offered a copy of the FINANCIAL POLICY named at the top of this page.

Patient Signature ___________________________

Date_______________________________



ACKNOWLEDGEMENT INFORMATION:

I, the undersigned, give permission to treat and assign directly to Omaha Health Clinic, all medical benefits, if any, otherwise payable to me for services rendered. I also understand that I am financially responsible for all charges not paid by my health benefits provider. I hereby authorize the use of this signature (or copy thereof) to provide necessary medical information to my insurance carrier upon their request. With my signature, I attest that I have sought the services of Omaha Health Clinic, and or Dr Kakish at my own will. I have not been solicited to receive these services. I am not aware that some of my tests may not be covered under my insurance plan and that I may be responsible for what doesn’t get covered.

 

OMAHA HEALTH CLINIC MEDICATION POLICY

It is our intention to keep you as healthy as possible as Omaha Health Clinic therefore we would like to advise you of our medication policy. Therefore it is the policy of Omaha Health Clinic that all patients who feel they are in need of an antibiotic must be seen by the physician for proper diagnosis of symptoms.

Omaha Health Clinic does not provide chronic pain management.

Please note that if you are on a narcotic for pain management that was prescribed by a previous provider Omaha Health Clinic will not be able to provide you with any refills. At the time of your appointment you will be referred to a pain specialist for further medication management. There may be certain circumstances where this policy does not apply and that is to the discretion of the physician. Thank you for choosing Omaha Health Clinic for your healthcare needs.

Also, at the time of your appointment if you are advised you will need lab work and are unsure of possible labs that will be drawn please reach out to our staff when in doubt or possible questions and or about the cost of the labs.

SIGNATURE___________________________

PRINT NAME__________________________

DATE_________________________________

 

Medical Information Release Form

(HIPAA Release Form)

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Release of Information

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This information may be released to:
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The release of Information will remain in effect until terminated by me in writing.

Messages

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Signed:_____________________________

Witness:_____________________________

Date:_______________________________

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IMPORTANT! All information presented in this website is intended for informational purposes only and not for the purpose of rendering medical advice. Statements made on this website have not been evaluated by the Food and Drug Administration. The information contained herein is not intended to diagnose, treat, cure or prevent any disease.

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