Medical
Information Release Form
If
you need a copy of your health information (medical record) for any
reason, you must make your request in writing on a HIPAA compliant
authorization form and forward to:
Health
Information Management Department
Chase County Community Hospital/Clinic
600
West 12th Street
Imperial,
NE 69033
Please
be advised that in Nebraska, the state sets the fee structure for
obtaining copies of your medical records as described in Legislative
Bill 17. Our Medical Records Clerk will contact you upon receipt of your
request to review any associated fees, if applicable. Please include a
phone number where we can reach you.
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For your convenience, there is an authorization form
that you can print out and fax to Health Information Management at 308-882-7341(hospital) or 308-882-7362(clinic).
CLICK HERE.
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For additional information, please contact our
Medical Records Clerk at 308-882-7271(hospital) or
308-882-7336(clinic).
