Patient Forms & Policies
Lincoln Pediatric Group in Lincoln, Nebraska
You may download and print any of the forms listed below before coming to our office. Make sure to print the forms on white paper only. You may either bring them with you to your visit or fax them to us before your appointment.
To view our forms, you will need Adobe Reader. You may download Adobe Reader for free by visiting www.adobe.com.
Teenagers under 19 years of age are minors and should be accompanied by a parent or guardian if possible. Paper work and questionnaires brought to the office should be signed by a guardian. A designee such as a relative may accompany your child if they have a signed note; we would encourage a guardian to be available by phone.
Insurance & Billing
Lincoln Pediatric Group participates with most major insurance plans in our area. Please call our office prior to your visit to make sure that we are in network with your insurance plan. We are NOT in-network with WellCare of Nebraska Medicaid. We will file your insurance claims for you if you have provided us with your current insurance information. To ensure claims are processed under the current policy, we will ask to see and/or copy your insurance card at each visit. We are also required to collect your co-payment at the time of service. If you do not have insurance, payment in full is due at the time of service. For your convenience, we accept cash, checks, MasterCard and Visa.
Immunizations are an important part of you child's health. They are also very expensive, and can cost hundreds of dollars. If you do not have insurance coverage for immunizations and you choose to have your immunizations at our office, we require payment in full prior to administering the immunizations. If immunization cost is a concern for you, the Lancaster County Health Department offers these same immunizations at a greatly reduced cost if you qualify. You can call them at 402-441-8065 for more information. Please feel free to speak to someone in our billing department at 402-489-3834 for further information about immunization payment.
You will receive a statement monthly as long as you have an unpaid balance. You are only billed for services which have been processed by your insurance company or for which no more insurance payments are available. The amount you owe is listed as “patient balance” on the statement and is due upon receipt of the statement. A 1% per month finance charge is added to overdue accounts. Please contact our billing department if you are unable to pay in full upon the receipt of your statement so that we can inform you of your payment options.