Patient Registration Forms
Every patient requires a Patient Registration Form, Adult Medical History form, or Minor Pediatric Medical History (infant to 18yo) Form,and Financial Disclosure. If you are unable to be present for your Minor child's accountment(age 0 to 18yrs); Fill out an Authorization to Treat Minor Patients. For those who have Medicare: Fill out a Medicare Secondary Payer Questionnaire Form Forms to release medical records: If you want to obtain records from a previous physician office or facility, please fill out Authorization to Release Medical Records Form. If you want Dermatology Specialists of Omaha to send their records to a different physician office or facility, please fill out Authorization to Use or Disclose PHI (send out records from DSO) Forms necessary for all new patients Espanol: Por Favor, llene los formularios necesarios a continuacion Cada paciente requiere Paciente Demográfico e Información de Seguror, Historia Clínica, Historia Clínica de Pediátricos y Adolescentes, y Financiera Revelacion Si no puede estar presente para el nombramiento del nino, llene Autorización a Tratar Pacientes Menores de Edad