MRHS New Patient Paperwork

New Patient Registration
Filling out this registration does not secure you an appointment. In order to schedule a new patient appointment you must call Midwest Regional Health Services at 402-745-1145.
Patient Name
Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Sex at Birth
Social Security #
Format: 000-00-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Preferred Language
Race
Ethnicity
How did you hear about us?

Insurance Information

Please have your insurance card available
Billing Address
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Primary Insurance Company
Ex: BCBS, United Healthcare, Aetna, etc.
Policy Number
Group Number
If applicable: insurances may not include a group number on your card
Policy Holder's name (if different than patient)
Hint: Who is the insurance through?
Date of Birth of Policy Holder (if different than patient)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insurance Company (if applicable)
Ex: BCBC, United Healthcare, Aetna, etc.
Policy Number
Group Number
If applicable: insurances may not include a group number on your card
Policy Holder's name (if different than patient)
Hint: Who is the insurance through?
Date of Birth of Policy Holder (if different than patient)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please attach a picture of your insurance card below.

Ensure the picture is clear & the entire card is captured. If you are unable to attach a picture please bring your card with you to your first appointment
Primary Insurance Front of Card
Primary Insurance Back of Card
Secondary Insurance Front of Card
Secondary Insurance Back of Card

Assignment and Release:
I understand that I am financially responsible for charges incurred for services rendered. Full payment is expected at the time services are rendered. As a courtesy to you, we will submit your medical claim to your insurance company. I hereby authorize, and assign direct payment of my medical insurance benefits to Midwest Regional Health Services, LLC. I also authorize my medical provider to release my information requested by my medical insurance company.
Signature of Patient or Legal Guardian
Name
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc

Please review the following MRHS Financial Policy
Signature of Patient or Legal Guardian
Name of Signee
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option

Please review the following MRHS HIPPA Policy
I authorize Midwest Regional Health Services to disclose personal health information to the following people:

(If you do not want any authorized individuals you may leave the following fields black)
Name
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc
Name
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc
I wish to have the following restrictions to the use or disclosure of my protected health information other than those listed in Midwest Regional Health Services Privacy Policy
Consent to Leave Phone Messages

Do you authorize Midwest Regional Health Services to leave detailed messages regarding your care or lab results on your preferred phone number?
Please Initial here ONLY IF YOU CONSENT to receive voicemails
Signature of Patient or Legal Guardian
Name of Signee
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty:

Emergency Contact Information