Patients may inspect, obtain copies of, or have copies of their medical records sent to another health care provider or other individual. Memorial Community Hospital & Health Systems are required under state and federal laws to obtain a complete and properly executed Release of Medical Information form before they may provide a copy of a patient’s records to anyone. In the event the patient is unable to execute the authorization, the patient’s legal representative may authorize the release of information.
To obtain medical records from Memorial Community Hospital & Health Systems please go to Services, Medial Records and download Consent to Release of Information Form.
When completing the authorization form:
- Indicate the dates of treatment for which you are requesting
- The type of records (use the appropriate check boxes)
- Be sure to check the appropriate boxes if requesting information regarding: Alcohol/Drug Abuse, Mental Health, HIV/AIDS related information (this information cannot be released without specific authorization)
If the patient is a minor, 18 or younger in Nebraska, or 17 years or younger in Iowa, the authorization must be signed by a parent or his/her legally qualified representative. Proof of legal representation will be required.
While patients may request their entire record, our experience has shown that information in documents such as the Discharge Summary, Operative Report and History and Physical contain the information that most patients are seeking. For clinic records, usually the last 2 years is sufficient for most requests.
Nebraska Revised Statute 71-8404
- A provider may charge no more than $20.00 as a handling fee
- No more than $0.50 per page as a copying fee.
- A provider may charge for the reasonable cost of all duplications of medical records which cannot routinely be copied or duplicated on a standard photocopy machine.
- A provider may charge an amount necessary to cover the cost of labor and materials for furnishing a copy of an X-ray or similar special medical record. If the provider does not have the ability to reproduce X-rays or other records requested, the person making the request may arrange, at his or her expense, for the reproduction of such records.
- If the reproduction charges are greater than $100, pre-payment will be required.
- Records provided for another medical facility or physician office will have fees waived.
Submitting the request
Complete and sign the appropriate medical records request form listed above, and submit it by mailing, emailing or faxing.
Memorial Community Hospital & Health Systems — Release of Information
810 N 22nd
Attn: Medical Records
You can also bring the signed Authorization Form to
Memorial Community Hospital & Health Systems (MCH&HS) — Health Information Management Department
Hours: Monday through Friday, 8 a.m. – 5 p.m.
You may also drop off your release form at any MCH&HS location.
Inspecting or requesting a copy of your medical records
You may only inspect records at the facility location
To schedule an appointment to inspect your MCH&HS records, please contact the Health Information Management Department. A photo ID will be required.
Processing time for copies of your records
Please allow 30 days for your request to be processed. You will be notified when your records are ready.
Picking up your requested medical records
If you plan to come to MCH&HS to pick up your records, please bring a photo ID.