Medical Records Requests
To obtain a copy of your medical records or request to have them sent to another healthcare facility, insurance company, attorney or another individual, you must first submit a completed, signed and dated authorization form-English or authorization form-Spanish.
Due to federal HIPAA regulations; we are obligated to make sure all sections of this release are clearly and legibly filled out before fulfilling the request. This will help make sure we are providing you with the information you need. If the authorization form is not filled out completely, it will be returned to you to be completed further. Please include a phone number to contact you if there any questions.
• If someone other than the patient is signing the release form, we would need documentation to support the signature (i.e. Power of Attorney Papers).
• If the patient is a minor, who is under the age of 19, the parent/guardian needs to sign for them. If the minor is emancipated, then we would need documentation to support this.
If you have any questions when completing the request form, please do not hesitate to call our Health Information Department at 402-644-7602 and our staff would be happy to assist you during our office hours of Monday – Friday 8:00am -4:30pm.
• Please specify the type of records that you are requesting and indicate the method of delivery.
• If you would like HIM to fax records to your doctor for an upcoming appointment, please provide the fax number.
Once the release of information form is completed, you can return the form using one of the methods below:
Mail: 2700 West Norfolk Avenue, Norfolk NE, 68701
Faith Regional Health Services
ATTN: Health Information
2700 W. Norfolk Ave.
Norfolk, NE 68701