Good Samaritan Clinic
Patient Information and Forms
We schedule appointments between 8 a.m.-12 p.m. and 1 p.m.-5 p.m.
- Call (308) 865-2370 for Internal Medicine, Gastroenterology, Infectious Disease, Neurology, Neurosurgery, Nephrology, Pulmonology, Palliative Care, and General Surgery.
- Call (308) 865-2363 for Family Medicine.
- Call (308) 865-2600 for Orthopaedics.
Please have all necessary information available prior to calling so that we can plan the best time for your visit. If you feel an appointment is needed on the day you call, please call as early in the day as possible. Please bring all medications with you to every visit, including all non-prescription medications or remedies you are currently using.
If you are a new patient to CHI Health Good Samaritan, we ask that you arrive 20 - 30 minutes prior to your scheduled time to complete the necessary paperwork. You can also print these forms off in advance, complete them and bring them with you to your appointment.
We ask that you provide us with your health insurance card and driver’s license to copy for your medical record. The driver’s license is only used for patient identification.
Need to reschedule or cancel?
Please call our office at least one day in advance if you are unable to keep your appointment.
Your CHI Health Good Samaritan Clinic billing statement will come from The Physician Network.
For refills, please notify your pharmacist 2-4 days prior to running out of medication to prevent undue lapses in your medication schedule. All prescriptions and authorizations for refills must be requested during normal clinic hours. Not all prescriptions can be refilled over the telephone. If you have no refills remaining on your prescription, you may need to schedule an appointment with your physician.
For your convenience, CHI Health Good Samaritan makes certain patient forms available online. Filling these out in advance of your first appointment could save you time when you arrive for your office visit.
If you have a specialized reason for your visit, please also fill out the specific form below.
- Auto Accident Information
- Consent to Treat and Financial Policy
- Medical Records Release
- Patient Information Sheet
- Patient Request for Sharing of Treatment/Billing Information with Family/Friends.
- Neurosurgical Form
- Workers Compensation
- Immunization Proxy Form
- Vaccine Information Statements