Medical Records Release Form

Please click on the hyperlink below to access our form for medical records release and either mail to our office or fax to 402-292-0119. Please note all medical records being released can take up to 30 days to complete upon receipt of written request.  In order to process your request, the form must be filled out COMPLETELY.  If you do not have all the information that is needed, please take home and return once you have completed the form.   If there is missing information, your request may not be processed in a timely manner.

The handling fee and cost per page must be paid in full upon receipt of medical records, whether they are picked up or faxed to another office.   Please be aware that if you fail to pick up your medical records once the request has been submitted and completed, you are still responsible for the handling fee.   By completing the form attached, you will be acknowledging your understanding of the fees involved with processing your request.

Medical Records Release