Phone: 402-399-9305
Fax: 402-397-3191

Forms

Please fill out these forms electronically and submit via email.

Patient Information Form
Patient Permission To Disclose Form
Treatment Agreement Form
Consent to Release Information to Physician Form
Privacy Notice
Personal Medication Form


If you are seeing Dr. Lubberstedt for the first time, please fill out:
Pre-Registration Information

Psychiatric Services, PC is implementing a new policy that all patients under the age of nineteen must have a credit card on file as all copayments, deductibles and co­insurance is due at the time of service. A receipt will be mailed to the person whose name is on the credit card. We are doing this as a convenience for the patient so they are not asked for payment on the day of the appointment.

We do accept Visa, MasterCard, Discover or American Express.

Thank you for your understanding and cooperation regarding this policy.

 

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