Patient Forms & Resources | ICHI Crete & Lincoln, NE

Patient Resources

Everything you need to prepare for your visit — schedule, complete forms, and access your health records, all in one place.

Schedule & Portals

Book or manage your appointment

Choose the option that fits you. Established patients can check in and manage visits through our portals; new patients can request an appointment below.

Existing Patients

Check in, update your information, and complete pre-visit paperwork through our secure Phreesia portal.

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Preferred for established patients — your information is already on file.

New Patients

Not an established patient yet? Request an appointment and we'll get you scheduled.

Request an appointment online Call (402) 826-3222 Email our office

We'll call you within 1 business day to confirm.

Health Records

View your health records, lab results, and messages through the FollowMyHealth patient portal.

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Schedule an Appointment

Request an Appointment

Fill out our online appointment request form below. Our team will confirm your appointment within 1 business day.

Schedule an Appointment

Request an Appointment

Click below to open our secure online appointment request form. Our team will confirm your appointment within 1 business day.

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Patient Forms

Complete your forms

Complete any form online — it will be emailed securely to our office — or download the PDF to print and bring with you. Click a form to expand it.

No-Show Policy AcknowledgmentEN

Review our appointment cancellation policy and sign to acknowledge.

This form is available in English. For Spanish or Russian assistance, please call (402) 826-3222.

Innovative Community Health Institute

Saline Medical Specialties • Lancaster Family Medicine

830 East 1st Street, Suite 200, Crete, NE 68333 4911 N. 26th Street, Suite 106, Lincoln, NE 68521 Phone: (402) 826-3222 • Fax: (402) 826-3228

Please correct the highlighted fields below.

No Show Policy

Effective Immediately, it is the policy of Innovative Community Health Institute LLC (ICHI), doing business such as, Saline Medical Specialties, Lancaster Family Medicine. that a patient is considered a “No Show” if an appointment is not cancelled at least 24 hours prior to the scheduled appointment time.

Three (3) No Shows per calendar year may subject a patient to termination from the clinic, and the patient may no longer be able to see any provider at ICHI. After three missed appointments, a $35 no-show fee will be applied to the patient’s account.

No Shows negatively impact care and clinic operations in the following ways:

Patients may not receive the timely care they need.
Providers experience gaps in their schedules.
Other patients who may have needed care lose the opportunity to be seen.

Insurance programs, including Medicaid, may require clinics to track missed appointments. Excessive no-shows may affect eligibility for scheduling accommodations.

Innovative Community Health Institute LLC reserves the right to modify this policy at any time. Patients may contact ICHI to obtain a current copy of the No Show Policy.

Acknowledgment

By signing below, I acknowledge that I have read and understand the No Show Policy of Innovative Community Health Institute LLC.

Revised 1/2026

Patient Name *

This field is required.

Date *

This field is required.

Signature *

This field is required.

Type your full name as your electronic signature

Relationship to Patient *

SelfParent/GuardianLegal RepresentativePower of Attorney

Please select an option.

Thank you!

Your form has been submitted and emailed to our office. If you need immediate assistance, please call us at (402) 826-3222.

No-Show Policy (PDF)Download, print, and bring the completed form to your visit.

Download PDF

Immunization Philosophy AcknowledgmentEN

Read our vaccine philosophy and sign to acknowledge.

This form is available in English. For Spanish or Russian assistance, please call (402) 826-3222.

Innovative Community Health Institute

Saline Medical Specialties • Lancaster Family Medicine

830 East 1st Street, Suite 200, Crete, NE 68333 4911 N. 26th Street, Suite 106, Lincoln, NE 68521 Phone: (402) 826-3222 • Fax: (402) 826-3228

Please correct the highlighted fields below.

Immunization Philosophy

At Innovative Community Health Institute LLC (ICHI), we are committed to providing high-quality, evidence-based medical care. Vaccines are a critical part of preventing serious diseases and protecting the health of individuals, families, and our community. We follow the current immunization schedules recommended by the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) for infants, children, adolescents, and adults.

Vaccines are safe and effective when given according to recommended schedules. Immunizations protect not only the person receiving the vaccine, but also vulnerable people around them, including infants, older adults, and those with weakened immune systems. Our providers regularly review new scientific data and vaccine recommendations to ensure that the care we provide is current and aligned with national standards.

For every vaccine we administer, ICHI will provide a Vaccine Information Statement (VIS) as required by federal law. The VIS explains the purpose of the vaccine, potential risks and side effects, and what to do if there is a reaction. You are encouraged to review the VIS and ask any questions before you or your child receive a vaccine.

We understand that there may be concerns about immunizations; however, our providers feel that there is no strong scientific evidence to withhold immunizations unless medically contraindicated. Decisions to delay or refuse vaccines increase the risk of preventable disease for both the patient and the community. We welcome questions and concerns about vaccines and will take time to discuss benefits, risks, and alternatives so that informed decisions can be made.

Acknowledgment

By signing below, I acknowledge that I have reviewed and understand the Immunization Philosophy of Innovative Community Health Institute LLC.

Revised 1/2026

Patient Name *

This field is required.

Date *

This field is required.

Signature *

This field is required.

Type your full name as your electronic signature

Relationship to Patient *

SelfParent/GuardianLegal RepresentativePower of Attorney

Please select an option.

Thank you!

Your form has been submitted and emailed to our office. If you need immediate assistance, please call us at (402) 826-3222.

Immunization Philosophy (PDF)Download, print, and bring the completed form to your visit.

Download PDF

Medicare Wellness CheckupEN

Annual wellness questionnaire, PHQ-9 depression screener, and medication list.

Innovative Community Health Institute

Saline Medical Specialties • Lancaster Family Medicine

830 East 1st Street, Suite 200, Crete, NE 68333 4911 N. 26th Street, Suite 106, Lincoln, NE 68521 Phone: (402) 826-3222 • Fax: (402) 826-3228

Please correct the highlighted fields below.

Complete the Medicare Wellness Checkup, the PHQ-9 depression screener, and your medication list below. Please bring this document back to us one week before your next appointment.

Name *

This field is required.

Date of Birth *

This field is required.

Date *

This field is required.

Medicare Wellness Checkup

1. During the past 4 weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue? *

Not at allSlightlyModeratelyQuite a bitExtremely

Please select an option.

2. During the past 4 weeks, has your physical and emotional health limited your social activities with family, friends, neighbors, or groups? *

Not at allSlightlyModeratelyQuite a bitExtremely

Please select an option.

3. During the past 4 weeks, how much bodily pain have you generally had? *

No painVery mild painMild painModerate painSevere pain

Please select an option.

4. During the past 4 weeks, is there someone available to help you if you need it and wanted help? (For example, if you felt very nervous, lonely, or blue; got sick and had to stay in bed; needed someone to talk to, or help with daily chores.) *

Yes, as much as I wantedYes, quite a bitYes, someYes, a littleNo, not at all

Please select an option.

5. During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes? *

Very heavyHeavyModerateLightVery light

Please select an option.

6. Can you get to places out of walking distance without help? (For example, can you travel alone on buses or taxis, or drive your own car?) *

YesNo

Please select an option.

7. Can you go shopping for groceries or clothes without someone's help? *

YesNo

Please select an option.

8. Can you prepare your own meals? *

YesNo

Please select an option.

9. Can you do your housework without help? *

YesNo

Please select an option.

10. Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house? *

YesNo

Please select an option.

11. Can you handle your own money without help? *

YesNo

Please select an option.

12. During the past 4 weeks, how would you rate your health in general? *

ExcellentVery goodGoodFairPoor

Please select an option.

13. How have things been going for you during the past 4 weeks? *

Very well: could hardly be betterPretty wellGood and bad parts about equalPretty badVery bad: could hardly be worse

Please select an option.

14. Are you having difficulties driving your car? *

Yes, oftenSometimesNoNot applicable, I do not use a car

Please select an option.

15. Do you always fasten your seat belt when you are in a car? *

Yes, usuallyYes, sometimesNo

Please select an option.

16. How often during the past 4 weeks have you been bothered by any of the following problems? *

Please answer every row.

17. Have you fallen two or more times in the past year? *

YesNo

Please select an option.

18. Are you afraid of falling? *

YesNo

Please select an option.

19. During the past four weeks, how many drinks of wine, beer or other alcoholic beverages did you have? *

10 or more drinks per week6-9 drinks per week2-5 drinks per weekOne drink or less per weekNo alcohol at all

Please select an option.

20. Do you exercise for about 20 minutes three or more days a week? *

Yes, most of the timeYes, some of the timeNo, I usually do not exercise this much

Please select an option.

21a. Have you been given information to help you with a hazard in your house that might hurt you? *

YesNo

Please select an option.

21b. Have you been given information to help you keep track of your medications? *

YesNo

Please select an option.

22. How often do you have trouble taking medicines the way you have been told to take them? *

I do not have to take medicineI always take them as prescribedSometimes I take them as prescribedI seldom take them as prescribed

Please select an option.

23. How confident are you that you can control and manage most of your health problems? *

Very confidentSomewhat confidentNot very confidentI do not have any health problems

Please select an option.

PHQ-9 Depression Screener

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself

Please answer every row.

If you are experiencing any of the problems in this form, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

Not Difficult at allSomewhat DifficultVery difficultExtremely Difficult

Please select an option.

List of Medicines

List all medications you are currently taking. Use “Add Another Medication” for more rows.

Medication NameColorWhat it's forDosageTimeSpecial instructions

Thank you!

Your form has been submitted and emailed to our office. If you need immediate assistance, please call us at (402) 826-3222.

Medicare Wellness Packet — English (PDF)Download, print, and bring the completed form to your visit.

Download PDF

Chequeo de Bienestar de MedicareES

Cuestionario de bienestar anual, cuestionario de depresión PHQ-9 y lista de medicamentos.

Innovative Community Health Institute

Saline Medical Specialties • Lancaster Family Medicine

830 East 1st Street, Suite 200, Crete, NE 68333 4911 N. 26th Street, Suite 106, Lincoln, NE 68521 Phone: (402) 826-3222 • Fax: (402) 826-3228

Please correct the highlighted fields below.

Complete el Chequeo de Bienestar de Medicare, el cuestionario de depresión PHQ-9 y su lista de medicamentos a continuación. Por favor, devuélvanos este documento una semana antes de su próxima cita.

Nombre *

This field is required.

Fecha de nacimiento *

This field is required.

Fecha *

This field is required.

Chequeo de Bienestar de Medicare

1. Durante las últimas 4 semanas, ¿cuánto le han molestado sus problemas emocionales como sentirse ansioso, deprimido, irritable, triste o desanimado? *

Para nadaLigeramenteModeradamenteBastanteExtremadamente

Please select an option.

2. Durante las últimas cuatro semanas, ¿su salud física y emocional ha limitado sus actividades sociales con amigos, familia, vecinos u otros grupos? *

Para nadaLigeramenteModeradamenteBastanteExtremadamente

Please select an option.

3. Durante las últimas 4 semanas, ¿cuánto dolor corporal ha tenido en general? *

Sin dolorDolor muy leveDolor leveDolor moderadoDolor intenso

Please select an option.

4. Durante las últimas 4 semanas, ¿hay alguien disponible para ayudarle si lo necesita y quiere ayuda? (Por ejemplo, si se sentía muy nervioso, solo o triste; se enfermaba y tenía que quedarse en cama; necesitaba a alguien con quien hablar, o ayuda con las tareas diarias.) *

Sí, tanto como quisieraSí, bastanteSí, algunas vecesSí, un pocoNo, para nada

Please select an option.

5. Durante las últimas cuatro semanas, ¿cuál fue la actividad física más difícil que pudo hacer por lo menos dos minutos? *

Muy pesadoPesadoModeradoLigeroMuy ligero

Please select an option.

6. ¿Puede llegar a sitios que no estén a distancia andando sin ayuda? (Por ejemplo, ¿puede viajar solo en autobús o taxi, o conducir su propio coche?) *

SíNo

Please select an option.

7. ¿Puede ir a comprar comida o ropa sin la ayuda de alguien? *

SíNo

Please select an option.

8. ¿Puede preparar sus propias comidas? *

SíNo

Please select an option.

9. ¿Puede hacer las tareas domésticas o quehaceres de la casa sin ayuda? *

SíNo

Please select an option.

10. Debido a algún problema de salud, ¿necesita ayuda de otra persona con sus necesidades de cuidado personal como comer, bañarse, vestirse o moverse por la casa? *

SíNo

Please select an option.

11. ¿Puede manejar su propio dinero sin ayuda? *

SíNo

Please select an option.

12. Durante las últimas 4 semanas, ¿cómo valoraría su salud en general? *

ExcelenteMuy bienBienRegularPobre

Please select an option.

13. ¿Cómo le han ido las cosas en las últimas 4 semanas? *

Muy bien: difícilmente podría estar mejorBastante bienLas partes buenas y malas son más o menos igualesBastante malMuy mal: difícilmente podría ser peor

Please select an option.

14. ¿Tiene dificultades para conducir su coche? *

Sí, a menudoA vecesNoNo es aplicable, no uso coche

Please select an option.

15. ¿Siempre se abrocha el cinturón cuando va en coche? *

Sí, normalmenteSí, a vecesNo

Please select an option.

16. ¿Con qué frecuencia durante las últimas 4 semanas le ha molestado alguno de los siguientes problemas? *

	Nunca	Rara vez	A veces	Frecuente	Siempre
Caerse o marearse al levantarse o ponerse de pie
Problemas sexuales
Problemas para comer bien
Problemas dentales o de dentadura postiza
Problemas con el uso del teléfono
Cansancio o fatiga

Please answer every row.

17. ¿Se ha caído dos o más veces en el último año? *

SíNo

Please select an option.

18. ¿Tiene miedo de caerse? *

SíNo

Please select an option.

19. ¿Cuántas bebidas de vino, cerveza u otras bebidas alcohólicas ha tomado en las últimas cuatro semanas? *

10 o más bebidas por semana6-9 bebidas por semana2-5 bebidas por semanaUna copa o menos por semanaNada de alcohol

Please select an option.

20. ¿Hace unos 20 minutos de ejercicio tres o más días a la semana? *

Sí, la mayoría de las vecesSí, a vecesNo, normalmente no hago tanto ejercicio

Please select an option.

21a. ¿Le han dado información que le ayude con peligros en su casa que podrían lastimarlo? *

SíNo

Please select an option.

21b. ¿Le han dado información que le ayude a llevar el control de sus medicamentos? *

SíNo

Please select an option.

22. ¿Con qué frecuencia tiene problemas para tomar los medicamentos tal y como le han dicho que los tome? *

No tengo que tomar medicaciónSiempre los tomo según lo recetadoA veces los tomo según lo recetadoRara vez los tomo según lo recetado

Please select an option.

23. ¿Qué confianza tiene en que puede controlar y gestionar la mayoría de sus problemas de salud? *

Muy seguro de mí mismo(a)Algo seguro de mí mismo(a)No me tengo mucha confianzaNo tengo ningún problema de salud

Please select an option.

Cuestionario de Depresión PHQ-9

En las últimas dos semanas, ¿con qué frecuencia le ha molestado alguno de los siguientes problemas? *

	Para nada	Varios días	Más de la mitad de los días	Casi todos los días
Poco interés o placer en hacer cosas
Sentirse decaído(a), deprimido(a) o sin esperanzas
Problemas para dormir o mantenerse dormido, o dormir demasiado
Sentirse cansado(a) o con poca energía
Falta de apetito o comer en exceso
Sentirse mal consigo mismo, o pensar que es un fracaso, o que se ha decepcionado a sí mismo o a su familia
Dificultad para concentrarse en cosas, como leer el periódico o ver la televisión
Moverse o hablar tan lento que otros lo han notado. O, al contrario, estar más inquieto o agitado de lo normal
Pensamientos de que estaría mejor muerto o de hacerse daño

Please answer every row.

Si está experimentando alguno de los problemas mencionados en este formulario, ¿en qué medida estos problemas le han dificultado realizar su trabajo, ocuparse de las cosas en casa o llevarse bien con otras personas? *

Para nada difícilAlgo difícilMuy difícilExtremadamente difícil

Please select an option.

Lista de Medicamentos

Enumere todos los medicamentos que toma actualmente. Use “Agregar otro medicamento” para más filas.

Nombre del medicamentoColor¿Para qué es?DosisHoraInstrucciones especiales

Thank you!

Your form has been submitted and emailed to our office. If you need immediate assistance, please call us at (402) 826-3222.

Paquete de Bienestar de Medicare — Español (PDF)Download, print, and bring the completed form to your visit.

Download PDF

	Never	Seldom	Sometimes	Often	Always
Falling or dizzy when standing up
Sexual problems
Trouble eating well
Teeth or denture problems
Problems using the telephone
Tired or fatigue