Health Information Services

Patient Request for Medical Records Form

Information we will need:

  • Full name
  • Date of birth
  • Specific items requested
  • Reason for request
  • Date of appointment (if the records are needed for a doctor's appointment)
  • Phone numbers where we can reach you

The first 10 copies are free. After that, each copy is $0.50 per page.

Click here to read our Privacy Policy.

Other Information

You must sign an authorization form if you want us to release your information to someone else. These forms are available at Nemaha County Hospital, Health Information Services Department. A competent adult must sign for themselves. A spouse cannot give authorization for release of records. If the adult is not competent, the Power of Attorney can sign the authorization. A minor must have signed authorization by a parent or legal guardian until they reach the age of 19. You may be asked to produce Power of Attorney, guardianship, or custody papers before we release the records.

If you have not been seen in the last 10 years, your record has been destroyed.

A personal health record is a collection of important information about your health. You actively maintain and update your PHR with medical information from all you healthcare providers. This can help improve the quality of care you receive, help reduce or eliminate duplicate tests allow you to receive faster, safer treatment and care in an emergency, and empower you to play a more active role in your own healthcare.

If you would like more information on personal health records, please visit www.myphr.com or contact the Health Information Services Department at Nemaha County Hospital.

To request records

Call (402) 274-4366, ext. 6424
Or fax Request Form to (402) 274-6118

Hours of Operation

Monday-Friday
7:00 a.m. - 4:30 p.m.