Forms

For your convenience, some commonly used forms are being made available for your review. These forms are for your information and do not need to be printed for your appointment.

New Patients

To expedite our check-in process, Midwest Allergy and Asthma Clinic, P.C. has included several common registration forms for your convenience. Please print the following forms and bring them completed to your appointment. Other forms may be required on your arrival.

Formas en Español – Por favor complete y imprima para su cita

School Forms

Please click here for detailed information regarding school forms.

If you are needing to provide your school or daycare with forms, please use our Asthma Action Plan below. This can be used for asthma and/or food allergy.

 

Management of Protected Health Information

Note: For questions related to the completion of these forms, please contact our Medical Records department at (402) 397-7400. To request medical information to be sent to another physician, your child’s school, to your employer, an insurance underwriter, or another party:

To Request:

  1. Patient treatment without a parent/legal guardian present;
  2. Care for a child or adult handicapped patient to obtain treatment when accompanied by someone other than the parent or legal guardian; and/or,
  3. Sharing of Protected Health Information (PHI) with someone other than the patient/parent or legal guardian (e.g., step-parent, grandparent, friend, adult child’s parents, etc.):