For Patients

Medical Records

For additional information, please contact our Medical Records Clerk at 308-882-7336. If they are unavailable please leave a detailed message and we will return your call as soon as possible.

Medical Information Release Form – PDF

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
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.

For your convenience, there is an authorization form that you can print out and fax to Health Information Management at 308-882-7341.

Authorization Form - PDF

Birth Certificate Information

You must contact the State of Nebraska, Vital Statistics to obtain a copy of your birth certificate.
You may do this online:
Or fill out this form and mail to the address on the form.

For any questions please contact Vital Records at:
Phone: 402-471-2871