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:

  • MM slash DD slash YYYY
  • I Authorize and Request to Release Medical Information to:

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