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
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.
To set up an automatic payment plan:
2015 Influenza Vaccination Information
Influenza vaccinations will begin at Midwest Allergy and Asthma Clinic, P.C. in September
Please click on the applicable .pdf file and read it prior to your vaccination at Midwest Allergy and Asthma Clinic, P.C.:
you will be asked if you have read the information prior to your vaccination. A paper copy will be provided at your request.
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.):
Informative information for our patients that have food allergies.
Note: All forms are for personal use only and are the intellectual property of Midwest Allergy and Asthma Clinic, P.C.