**After you complete this form, please return to the Patient Information page to complete a Release of Information form.
**Please fill out a Release of Information form in order for us to coordinate care.
Note: If submit button is not working, required information is not filled out.
Please scroll up to double check your information.
8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | firstname.lastname@example.org
Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809
Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410