Download Dr/ID#: 3901 Pine Lake Rd, Suite 220 Lincoln, NE 68516 Ph. 402

Dr/ID#: _________________________
Kenneth J. Cheloha, M.D.
Ritoo Jain, M.D.
Michael A. Pace, M.D.
Jason Potts, M.D.
Shawn D. Semin, M.D.
Jodi I. Triggs,
3901 Pine Lake Rd, Suite 220
Lincoln, NE 68516
Ph. 402-421-3240
Daniel B. Einspahr, M.D.
Holly L. McMillan, M.D.
Lewis W. Plachy, M.D.
Mark D. Reida, M.D.
Gerold J. Stark, M.D.
D.O.
Lincoln Internal Medicine Associates is excited to announce the arrival of their new patient portal.
Question you will need to answer:
What we need from you:
By completing the following information I am agreeing to online communications between myself and Lincoln Internal
Medicine. I understand that my password is my own, but if I share it they also will have access to my chart information. I
understand that my chart may contain sensitive information such as mental health, substance abuse, HIV/STDs, and/or
reproductive/genetic diseases.
Print Patient’s Name: _________________________________________
Date of Birth (mm/dd/yyyy): _____/______/_______
Your Email address:
Security Question (Pick One):
[ ] What is your oldest sibling’s middle name?
[ ] What is your mother’s maiden name?
[ ] What is your favorite color?
[ ] Which city were you born in?
Security Answer:
___________________________________________________________________
*Be prepared to answer the security question if you need us to reset your password.
Communication Preference:
[ ] Printed – Lab results, reminders, etc will be sent to you via US Mail
[ ] Electronic – Lab results, reminders, routine communication, etc will be sent to you within the WebView portal.
You will receive an e-mail stating you have a message from Lincoln Internal Medicine and to log into your account to
view it when we have completed your account set up. Thank you.
What does this mean for you the patient?
Test results in real time (no need to wait for the mail)
Quicker communication with our practice
Send a message to our practice
It’s there to assist you in managing your care
[ ] I Decline – Due to no computer.
Ability to view, download and transmit sections of your
medical chart
View your appointment dates and times
View your medications, allergies and problem list
Your link is to your “chart” and is secure
[ ] I Decline – Due to no E-mail address.
By checking the box above and signing below I acknowledge I have been notified of LIMA’s patient portal
(Webview) where I would be able to view my records, etc from home. I am not interested in participating.
X____________________________________________________
Date: __________________________
Please return this form to a receptionist or your nurse.
For Office Use Only:
User ID: ___________________________________
Centricity: ________
Comm. Pref: ________
Other Data: ________
Chart Reviewed: ________
Configuration: ________
Message: ________