top of page
Patient Registration
First Name
Date of Birth
Social Security Number
e-mail Address
MIddle Initial
Last Name
Address
Phone - Best Contact
Employer Name
Pharmacy Name
Pharmacy Phone Number
Emergency Contact
First Name
Last Name
Address
e-mail Address
Phone - Best Contact
Insurance and Verification
To streamline the check-in progress, please upload your state or federally issued ID as well as your most recent insurance card. If you don't have secondary insurance, you can leave the third upload empty.
​
Only PDF or image files are accepted.
***PLEASE NOTE*** If you do not upload any insurance information, then you will be charged $200.00 at the time of service.
I attest that the above information is accurate and will exactly match the information provided at the time of service. Furthermore, I agree to receive e-mail notifications from secure@omahainsomnia.com, a HIPAA-compliant domain. I understand that Omaha Insomnia and Psychiatric Services will never release my information to a third party without my consent.
bottom of page