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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IN CASE OF EMERGENCY, WHOM SHOULD WE CONTACT?
PROTECTED HEALTH INFORMATION MAY BE RELEASED TO:
(personal information can be shared with)

Medical Information Release Form

(HIPAA Release Form)

Signed:_____________________________

 

Witness:_____________________________

 

Date:_______________________________

 

This information may be released to:

The release of Information will remain in effect until terminated by me in writing.
Messages:
Please list all the names of the medications with dosage and how often medication is taken:

 

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_________________________________

 



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 that 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 $35.00 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.

 

 

SIGNATURE___________________________

 

PRINT NAME__________________________

 

DATE_________________________________

 



New Office Policy as of 01/01/2020:

*If you have a balance that is due and owing of $200.00 or more you will need to make a payment before you are seen per our billing company.

*If you have new insurance, please let staff know and provide your new insurance information to us within 24 hours to avoid any delays or any billing issues;

*All of our diabetic patient’s need to be seen every 3 months.

*Patients that are currently taking depression, anxiety and or adhd medications will be required to be seen every 3 months. Also, please note that there may be a random urine drug screen to confirm the usage of medications.

*Please keep in mind and plan accordingly that our office will not prescribe or refill any controlled substance medications after office hours or over the weekend.

*Also, if you are needing a medication refill, please contact your pharmacy. If your medication is a controlled substance medication, please call our office for the refill request and or possibly an office visit for the refill request.

*Lastly please note that we cannot prescribe or call-in medications that have never been prescribed to you from our office without patient being seen first.



Effective 07/26/2021
Cancellation Policy/No Show Policy:

Our goal is to provide quality medical care in a timely manner. In order to do so we have had to implement an appointment/cancellation policy. The policy enables us to do better utilize available appointments for our patients in need of medical care. 

1. Cancellation/No Show Policy for Doctor Appointments. We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment book. A "no show" is someone who misses an appointment without canceling it within a 24-hour working day in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner. 

2. How To Cancel Your Appointment. If it is necessary to cancel your scheduled appointment, we require that you call one working day in advance. Appointments are high in demand, and your early cancellation will give another person the possibility to have access to timely medical care. To cancel an appointment, please call our office 8:00 am through 4:30 pm at (402) 933-4450. You may also cancel via text message within 24 hours after office hours at (402) 933-4450. 

3. Scheduled appointments. We understand that delays can happen, however, we must try to keep the other patients and doctors on time. If you are running late, please notify the office. If a patient is 15 minutes past their scheduled time, we may have to reschedule your appointment. 

The following are charges for services in the office: Same Day Appointment Cancellation $35.00 No Show Fee- $70.00 

Please sign to acknowledge you have read and understand our cancellation/no show policy. Thank you, Omaha Health Clinic.



Patient Name: ________________

Date: __________________



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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