Forms
Lincoln Pediatric Group Patient Forms
Pre-registration is REQUIRED prior to every visit via the
portal.
Some forms are available for download. You can download and print before coming to our office. Make sure to print the forms on white paper only. Well Child Check forms found on the portal (CHADIS); please complete forms prior to coming to your child's appointment. If unable to complete prior to appointment please arrive 15 minutes early to allow time to complete in office.
Release of Information (Medical Records)
If you would like to request a copy of your medical records or authorize Lincoln Pediatric Group to release your child's medical records to another healthcare provider, school, or other authorized individual or organization, please complete our Release of Information form.
How to Submit Your Request
- Download the fillable Release of Information (ROI) form below.
- Complete all required fields.
- Sign and date the form.
- Save the completed form to your device.
- Email the completed form to roi@lpgmd.com
You may also:
- Fax the completed form to 402-489-5049.
- Mail it to our office.
Please note:
- A parent or legal guardian must sign for patients under 19 years of age unless otherwise permitted by law.
- Incomplete forms may delay processing.
- Please allow up to 30 business days for your request to be processed.
If you have questions or need assistance completing the form, please contact our office.
To view our forms, you will need Adobe Reader. You may download Adobe Reader for free by visiting adobe.com.
Consents & New patient Forms
Additional Office Forms
Behavioral Health Forms
Anxiety
Autism Screening
ALL Visits for medication checks
Depression
Depression
Well Child Physical Forms
- If your child is scheduled for a Well Child Visit, you will need to login to your child's portal to complete the CHADIS forms.
- At well-child visits, patients age 11 and older may be asked to complete a private questionnaire. Questions are age-appropriate and may cover topics such as school, friendships, mental and emotional well-being, substance use, personal safety, relationships, and other health and lifestyle topics. These questions help our healthcare team better understand your child and provide the best care possible. The questionnaire gives your child an opportunity to share information they may not feel comfortable discussing in front of others.
Foster Care / Temporary Guardianship
If your child is in foster care or under a temporary guardianship, please provide our office with the appropriate legal documentation and complete our Foster Care/Guardianship Information Form. This information helps us keep your child’s records accurate and ensures we know who is authorized to make decisions and receive information about your child’s care.
We can only discuss your child’s medical information with individuals who are listed as authorized on the formal legal documentation on file with our office. Please provide updated legal documentation and a new form if the custody or guardianship arrangement changes.
Our office form helps us collect important information, but it does not replace required legal documentation.
