Request For Itemized Statement If you would like to request an itemized statement from Children’s Nebraska, please provide the following information. If you want to request an itemized statement from a Physician, you will need to call the phone number listed on your statement. Patient Information First Name Last Name Date of Birth MM/DD/YYYY Patient ID Date of Service MM/DD/YYYY Individual Requesting Statement First Name Last Name Email Address Phone Number Address Street Address Street Address Line 2 City State Zip Code