Patient Registration

Patient Registration

Part of the benefit of coming to our clinic is not having to wait forever to get started! We want you to get in and out and on with life as quickly as possible. We understand our patients have many things going on in their busy schedules and filling out forms in a waiting room is the last thing they want to do.

Pre-registration can cut an extra 15-20 minutes off your initial visit. Whether or not you have ever been a patient at our clinic you can pre-register by following the simple steps below!

TO USE PRE-REGISTRATION

1. Call our office to answer a few questions and make an appointment for a new evaluation. (402) 488-4282

2. Print the following forms then read, sign, date and bring them with you on your first visit, or if you don’t have a printer, you can fill them out at our clinic. As part of our policy, we ask that all information on the form is complete and accurate or we may not be able to bill for our services.

Patient Information/Medical Consent/Financial and HIPAA Agreement
Patient Intake Questionnaire

3. United Health Care requires their clients to fill out the following forms to gain authorization.

Required by all UHC Patients
UHC Patient Summary Form

AND…choose the form that matches your injury area
UHC Neck
UHC Back
UHC Shoulder, Arm, Wrist, Hand
UHC Hip, Leg, Knee, Ankle

BE SURE TO BRING WITH YOU:

Doctor’s Prescription (if not faxed directly to us)
Insurance Card(s)
Drivers License
Lawyer Information (if applicable)
Workers Comp Information (if applicable)

HIPAA INFORMATION AND PRIVACY PRACTICES

For a copy of our HIPAA Privacy Practices document click the link below. Also, if you would like for us to release any information to other parties not covered in our HIPAA Privacy Agreement you must fill out the Authorization to Disclose form below and specify who and what can be released.

Exstrom Physical Therapy HIPAA Privacy Practices

Authorization to Disclose Form