PATIENT FORMS

The following forms are made available in their electronic format for your convenience.  Please feel free to download and complete the forms prior to your appointment.

< Waiver for Treatment Form

< CHI-Methodist Release of Medical Records Form – The “CHI-Methodist Release of Medical Records Form” is for parents who are coming to OUR clinic and authorizing our staff to look into the patient’s previous records online at CHI or Methodist Health Systems.

< Authorization to Release Healthcare Information Form – The “Authorization to Release Healthcare Information Form” is for parents who are coming to OUR clinic and authorizing our staff to request access or copies of the patient’s previous records at other clinics and healthcare facilities.

< Contact Authorization Form

< Authorization For Beyond Care Pediatrics To Release Healthcare Information Form – The “Authorization For Beyond Care Pediatrics To Release Healthcare Information Form” is for parents who wish to leave our clinic and would like us to send their child’s records elsewhere.

 

Phone: (402) 991-5690
Fax: (531) 600-6282
16945 Frances ST, STE 200B
Omaha, NE 68130