Forms

For your convenience, some commonly used forms are being made available for your review. If you prefer to print and complete the forms prior to your visit to Midwest Allergy and Asthma Clinic, P.C., you are welcome to do so. If you wish to fax a completed form to our attention, please submit it to (402)-397-0115

New Patients

To expedite our check-in process, Midwest Allergy and Asthma Clinic, P.C. has included several common registration and patient forms for your convenience. Other forms may be required on your arrival.

Please complete the Patient History form and bring it with you to your first visit.

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.):