Lincoln Family Medical Group

Common Forms

Select the form that best matches your visit type.
If you are unsure which form to complete, please call our office.
402-488-7400

Start Here

Choose one of our guided form pages for the most common visit types.

New Patient Forms Medicare Wellness Forms New Counseling Forms
Patient demographic form
Patient Demographic Form

Please fill out Patient Information, Contacts, Guarantor Information, Insurance Information, and Sign/Date HIPAA Acknowledgement.

Fill Out Online
-OR-
Print Demographic Form
New patient intake form
New Patient Intake Form

Fill out if you are a new patient to our clinic.

Fill Out Online
-OR-
New Patient Intake Form
Medicare wellness form
Medicare Wellness Pre-Visit Questionnaire

Please fill out ONLY if you are having your Medicare Wellness Exam.

Fill Out Online
-OR-
Print MCW Pre-Visit Form
Records transfer request
Records Transfer Request

Please fill out to request your records from a previous clinic to be transferred to Lincoln Family Medical Group.

Fill Out Online
-OR-
Print Records Transfer Request
Authorization for friend or relative
Authorization for Friend, Relative, or Caretaker

Please fill out consent form if you would like LFMG to disclose medical information to a friend, relative, or caretaker.

Fill Out Online
-OR-
Print Authorization for Friend, Family, or Caretaker
HIPAA privacy notice
HIPAA Privacy Notice

Detailed information about how we protect your privacy.

HIPAA Notice of Privacy Practices

If you have files to be uploaded to our Medical Records department please click the button below.

PauBox Secure File Upload

For Counseling forms, please click below.

Counseling Forms