Record Request

If you are requesting an image disc and will be picking it up yourself, please call 402-484-6677. Do not fill out the information below.
If you wish to request an image disc to be picked up by a third party, please fill out the information below. The disc must be picked up within 30 days.

Authorization for release of information on:
Name*
First Last
Other/Previous Names
Birthdate*
MM slash DD slash YYYY
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I Authorize and Request to Release Medical Information to:
Name of person/agency requesting information*
Relationship to Patient
I release the following:
- Radiology Films
- Radiology Reports
Other
For date(s) of service on:
*
- I UNDERSTAND THAT I MAY REVOKE THIS RELEASE OF INFORMATION AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION HAS BEEN TAKEN. IN ANY EVENT, THIS AUTHORIZATION EXPIRES 12 MONTHS FROM THE ABOVE DATE.
Reason for disclosure*
Signature

Record Request

Authorization for release of information on:

I Authorize and Request to Release Medical Information to: