Please present your insurance card and a driver’s license or picture ID to the Patient Scheduler. Prior authorization may be required before you see one of our providers.

Assignment of Benefits

I hereby authorize Nebraska Cancer Specialists, the Physicians of Oncology Hematology West PC, to furnish my insurance company(s) or designated attorney, all information which they may require in order to issue payment. I herby assign all payment(s) for services rendered by NCS to be issued directly to Nebraska Cancer Specialists. This assignment applies to all dates of service until revoked.

I have requested medical services from Nebraska Cancer Specialists and understand by making this request I become fully responsible for any and all charges incurred in the course of the treatment

I give permission for Nebraska Cancer Specialists (NCS) to render to me medical treatment. I also understand I have the right to refuse any procedure or treatment and to discuss all medical treatments with my provider.

My signature below acknowledges that I have been offered the Notice of Privacy Practices and Patient Rights and Responsibilities (a copy is available at the office upon request).

Nebraska Cancer Specialists is committed to protecting our patient’s privacy. Without authorization, messages left on answering machines, via voicemail, or with other individuals will be limited to the caller’s name that they are calling from Nebraska Cancer Specialists, and the phone number to call. If you prefer that more complete information be provided, please fill out the form below.