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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.
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