General Information

Flu ‘Shot on the Spot’

Flu Shot Consent Form

Flu Shot for Insurance Submission Form

Suicide Prevention

National Suicidtion Lifel 1-800-273-8255.

Helpful websites:
13 Minutes
Suicide Prevention Lifeline
The Kim Foundation

Billing Questions

    • For unresolved issues or suggestions regarding billing or an experience at BCHC please complete the following form.

Patient/Visitor Issues or Suggestion Form

  • For help with your current bill, call 402-395-2191 and ask for Patient Financial Services.
  • For help with a bill that is past due:
    • If you got the bill before January 2, 2018, call 402-395-3268.
    • If you got the bill after January 2, 2018, call 308-398-3955.
  • For a loan to help pay off your medical bills, call Nancy at Cornerstone Bank 402-395-2151.
  • Flu “Shot on the Spot” Forms

Sports Physical Registration

Sports Physical Consent Form

Healthcare Rights

Financial Assistance Covered Providers
Financial Assistance Policy
Financial Assistance Summary
Advanced Directives
Patient Bill of Rights
Privacy Policy
Nondiscrimination Policy

Patient Forms

Title it Sports Physical Registration Form
Financial Assistance Application
Release of Health Information Form
Patient Service Agreement Clinic – Outpatients
Patient Service Agreement Clinic – Outpatients – Spanish
Patient Service Agreement
Patient Service Agreement – Spanish


2018 Community Health Needs Assessment
Patient/Visitor Grievance Form
Health Insurance Marketplace Authorization Form
Payment Guidelines
Functional Needs Registry Information
Dispose of unused, unwanted, or expired medications