Patient Registration

First Name

Date of Birth

Social Security Number

e-mail Address

MIddle Initial

Last Name

Address

Phone - Best Contact

Employer Name

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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. 

Upload ID
Insurance
Secondary Insurance

***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.