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11919 Grant St., Ste. 100 Omaha, NE 68164

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You are here: Home / Popp Cosmetic New Patient Form

Popp Cosmetic New Patient Form

New Patient Registration Form

  • Patient Registration

    This online form is divided into 4 sections: 1) Patient Registration; 2) Medical History; 3) Financial Policy and Statement of Responsibility; and 4) HIPAA Authorization to Disclose to a 3rd Party. Please complete all of the sections in their entirety. These forms are for secure ELECTRONIC SUBMISSION ONLY. If you are having difficulty please call (402) 391-4558.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Referred by Address
  • Insurance Information

  • Release of Information

    Initial by checking this box
  • Assignment of Benefits

    Initial by checking this box
  • HIPPA Privacy Notice

    Initial by checking this box
  • Consent to Medical Treatment

    Initial by checking this box
  • 2-Medical History

  • Date Format: MM slash DD slash YYYY
  • Please answer the following questions as accurately as possible:

  • Are you taking any of the following frequently, regularly or once in a while?

  • Is there a history of any of the following conditions in your family?

  • I have completed this form fully and completely, and certify that I am the patient or legally authorized agent of the patient.

  • Date Format: MM slash DD slash YYYY
  • 3-Financial Policy and Statement of Responsibility

  • We are pleased that you have chosen us for your health care needs. The following information regarding financial matters should be helpful to you in understanding our billing process.

    For Patients with Insurance: We will bill most insurance carriers for you when proper paperwork, including insurance cards, is provided to us. We will also bill most secondary insurance companies for you. Co-payments and deductibles are due at the time of service or prior. It is the patient's responsibility to obtain any referrals that are necessary for the visit.

    Medicare Patients: We will bill Medicare for you. We will also bill secondary insurance carriers for you. All co-payments, or a deductible, are due and payable at the time service is provided.

    Welfare Patients: All Welfare patients must provide a CURRENT VALID card before being seen.

    Liability Claims & Auto Accidents: We will file any insurance claims for services related to an auto accident or third party liability. We DO NOT however, wait for payment until settlements are complete. Payment for services is due at the time of service.

    Worker's Compensation: If your injury is work-related, we will need the case number, carrier name, and information prior to your visit in order to bill the Workers' Compensation insurance company. The patient is ultimately responsible for all fees if a Workers' Compensation claim is denied.

    Self Payment Accounts: We ask that you make payment at the time of the visit. We are happy to accept payment by cash, check, or credit card (except American Express). If your account reaches 90 days past due and you have not contacted us to make payment arrangements, your account may be turned over to a collection agency.

    Cosmetic Services: Your initial consultation is free of charge (except breast or butt augmentation). We do ask for a credit or debit card number at the time of scheduling your appointment to ensure that you come at your scheduled date/time. If you need to cancel or reschedule at any time, we ask that you call us to do so. If there is no call to cancel and you do not come in for your appointment, there is a non refundable $100 charge. All cosmetic services and/or purchases are paid at the time of service and will not be filed with your insurance company.

    Please check each line
  • For the convenience of our patients, we do accept VISA, MASTERCARD and DISCOVER (AMERICAN EXPRESS NOT ACCEPTED). Our payment options include Care Credit.

  • Date Format: MM slash DD slash YYYY
  • 4-Authorization to disclose your personal health information to another party

    By completing this form, you are giving Popp Cosmetic Surgery, P.C., permission to speak to another person(s) about your Personal Health Information (PHI) and to give them information such as diagnosis, course of treatment, prognosis, results of tests, how best to care for you after surgery, billing and payment specifics and any other such information as we would normally give directly to the patient.
  • If any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care options).
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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Popp Cosmetic Surgery PC

Business Hours: Mon-Thur, 9-5pm.
Fri, 9-4pm.

Payments Accepted: Visa, Mastercard, Discover, Insurance, Financing

11919 Grant St. Suite 100
Omaha, NE 68164

Phone: (402) 391-4558
Fax: (402) 391-7401
Email: staff@poppcs.com

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Located at the corner of N 120th St and Grant St