(402) 489-3834 Make a Payment MEET US OUR OFFICE FOR PARENTS PEDIATRIC SERVICES FORMS & POLICIES WHAT’S NEW CONTACT US Main Navigation Forms & Policies In This Section Forms & Policies Insurance & Billing Insurance & Billing FAQ Pay Your Bill Online Join Our Mailing List In This Section Parent Resources View Our Online Library » Lincoln Pediatric Group Patient Forms & Policies Pre-registration is REQUIRED prior to every visit via your appointment reminder text or email from Phreesia! 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. Some forms maybe attached to the Phreesia link; please complete online forms prior to coming to your child's appointment. If completing a paper form remember to bring them to your appointment. To view our forms, you will need Adobe Reader. You may download Adobe Reader for free by visiting www.adobe.com. Consents & New patient forms New Patient - Medical History Form New Patient - Authorization to get records from another office sent to LPG Authorization to release records from LPG 19 & older consent- Permission for Verbal Communication Consent to Receive Unencrypted Email or Text Consent for Non-Parental Caregivers Patient & Parent Questionnaires ALL Visits for: Mood, Anxiety, Depression, Behavior and ADHD Anxiety - Adult SCARED Anxiety - Child SCARED Anxiety - GAD-7 Depression - PHQ- 9 Behavior - ADHD Checklist Behavior - Vanderbilt Parent Behavior - Vanderbilt Teacher Pre-op HP Form Physical Forms Newborn forms are attached to Phreesia 2 week forms are attached to Phreesia 1 month forms are attached to Phreesia 2 month forms are attached to Phreesia 4 month forms are attached to Phreesia 6 month forms are attached to Phreesia 9 month forms are attached to Phreesia 12 month forms are attached to Phreesia 15 month forms are attached to Phreesia 18 month forms are attached to Phreesia 2 year forms are attached to Phreesia 3 year forms are attached to Phreesia 4-6 yr Forms are attached to Phreesia 7-10 year forms are attached to Phreesia 11+ Physical forms are attached to Phreesia Practice Policies 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. Financial Policy Appointment Information Medicaid Primary Care Change Form Important information regarding newborns and coordination of benefits Notice of privacy practices Vaccine Philosophy Statement Application for Employment Notice of Nondiscrimination - English Notice of Nondiscrimination - Other Languages 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 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, Visa, Discover and American Express. Immunizations are an important part of your 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 option 2 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. 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 our palyment plan options through Phreesia and our partnership with Union Bank and Trust. Lincoln Pediatric Group 4501 S. 70th St., Suite 110 Lincoln, Nebraska 68516 Phone: (402) 489-3834 Fax: (402) 489-5049 Home | Meet Us | Our Office | For Parents | Expecting | Forms & Policies | What's New | Contact Us Privacy Policy | Photo Disclaimer | Sitemap Copyright 2021 Lincoln Pediatric Group. pediatric web design by practis, inc