Medical records

Request Records by Completion of Authorization Form or Patient Access Request Form

Medical records can be requested by downloading, printing and completing the “Authorization for Use or Disclosure of/Access to protected health information” form (to authorize disclosure of records to another person or organization) or  “Patient access request to their protected health information” form (to request access to own records).  If questions on completing the form, contact the hospital release of Information representative at the below phone number.

Authorization for use or disclosure of/access to protected health information form

• Medical records request and authorization
• Request form (Spanish)
• Request form (Vietnamese)
• Request form (Simplified Chinese)
• Request form (Traditional Chinese)

Patient access request to their protected health information form

• Patient access request
• Request form (Spanish)
• Request form (Vietnamese)
• Request form (Simplified Chinese)
• Request form (Traditional Chinese)

Amendment to protected health information

• Patient request for an amendment to protected health information

Submit the completed authorization form or access request form by mail, fax, or email to the hospital at which you received care:

CHI Health Creighton University Medical Center - Bergan Mercy

Attn: Health Information Management (Release of Information)
7500 Mercy Rd
Omaha, NE 68124
Phone: (402) 398-6803
Fax: (402) 398-6016
Email: [email protected]

CHI Health Good Samaritan

Attn: Health Information Management (Release of Information)
10 E 31st St
Kearney, NE 68847
Phone: (308) 865-7945
Fax: (308) 865-2926
Email: [email protected]

CHI Health Immanuel

Attn: Health Information Management (Release of Information)
6901 N 72nd St
Omaha, NE 68122
Phone: (402) 572-2097
Fax: (402) 572-2054
Email: [email protected]

CHI Health Lakeside

Attn: Health Information Management (Release of Information)
16901 Lakeside Hills Ct
Omaha, NE 68130
Phone: (402) 717-8041
Fax: (402) 717-8040
Email: [email protected]

CHI Health Mercy Corning

Attn: Health Information Management (Release of Information)
603 Rosary Dr
Corning, IA 50841
Phone: (402) 717-1792
Fax: (402) 717-0032
Email: [email protected]

CHI Health Mercy Council Bluffs

Attn: Health Information Management (Release of Information)
800 Mercy Rd
Council Bluffs, IA 51503
Phone: (712) 328-5924
Fax: (712) 328-5932
Email: [email protected]

CHI Health Midlands

Attn: Health Information Management (Release of Information)
11111 S 84th St
Omaha, NE 68046
Phone: (402) 593-3336
Fax: (402) 593-3353
Email: [email protected]

CHI Health Missouri Valley

Attn: Health Information Management (Release of Information)
631 N 8th St
Missouri Valley, IA 51555
Phone: (402) 717-1792
Fax: (402) 717-0032
Email: [email protected]

CHI Health Nebraska Heart

Attn: Health Information Management (Release of Information)
7500 S 91st St
Lincoln, NE 68526
Phone: (402) 219-7568
Fax: (402) 219-7289
Email: [email protected]

CHI Health Plainview

Attn: Health Information Management (Release of Information)
704 N 3rd St
Plainview, NE 68769
Phone: (402) 717-1792
Fax: (402) 717-0032
Email: [email protected]

CHI Health Schuyler

Attn: Health Information Management (Release of Information)
104 W 17th St
Schuyler, NE 68661
Phone: (402) 717-1792
Fax: (402) 717-0032
Email: [email protected]

CHI Health St. Elizabeth

Attn: Health Information Management (Release of Information)
555 S 70th St
Lincoln, NE 68510
Phone: (402) 219-7731
Fax: (402) 219-7289
Email: [email protected]

CHI Health St. Francis

Attn: Health Information Management (Release of Information)
2620 W Faidley Ave
Grand Island, NE 68803
Phone: (308) 398-5506
Fax: (308) 398-5699
Email: [email protected]

CHI Health St. Mary's

Attn: Health Information Management (Release of Information)
1301 Grundman Blvd
Nebraska City, NE 68410
Phone: (402) 873-8922
Fax: (402) 874-5201
Email: [email protected]

Medical Record Copy Fees

• For records sent directly to a provider or other health care facility for continuing care, there is no fee.
• For patients only, below are the standard fees to produce a copy of your medical records. In some states patients may receive nominal pages for free based on the lower of a state or federal rate.
  
  • Electronically maintained records delivered in electronic format $6.50
    
  • Electronically maintained medical records combined with paper records delivered in Electronic format are billed at $6.50 (for the electronic portion) + $0.09 per page (for the paper portion) for labor involved in creating an electronic copy of the records maintained on paper
    
  • Electronically maintained records delivered on paper are $1.15 for labor cost to create the paper copy of the record maintained electronically plus $0.06 per page for paper and toner
    
  • Paper records delivered in electronic format are $0.09 per page for the labor involved in creating an electronic copy of the records
    
  • Paper records delivered on paper are $0.15 per page
    
• Plus, postage and applicable taxes
  

Processing Your Request

• In most cases, record copies are available in less than a week, however some requests may take longer to process.
• If you have questions or need to verify the status of your submitted request, please contact the facility at the above phone number.

CHI Health and CHI Health Clinic have partnered with Datavant and MediCopy services for the release of protected health information (PHI), otherwise known as medical records. Your medical record includes, but is not limited to your medical history, diagnosis, treatment as well as lab results and reports from previous testing and procedures.

To request a copy of your medical records, we ask that you fill out an authorization. You can complete an authorization by following one of the options below. If the patient is a minor, or unable to sign an authorization, the signature of an authorized legal guardian is required. Once your authorization is submitted, please allow two business days before calling to check status.

Request your records online

Fill out an online authorization form. Your authorization will open in your internet browser. If you need to refer back to this page please right click to open in a separate tab. Please note that a valid email address is required when submitting an online authorization and to complete the submission process, you must check your email and verify your request for medical records.

• Medical records authorization download
• Behavioral health authorization download

Email your request

Please print an authorization. Once you have filled out your authorization in its entirety, you may securely email it directly to MediCopy at [email protected].

Amendment to protected health information

• Patient request for an amendment to protected health information

Submit the completed authorization form or access request form by mail, fax, or email.

Mail your request

Please print an authorization. Once you have filled out your authorization in its entirety, you may mail it directly to MediCopy at:

MediCopy services, Inc.
Attn: Record request – CHI Health clinic
8 City Blvd., Suite 400
Nashville, TN 37209

After MediCopy receives your completed authorization, your request will be processed as quickly as possible and within 30 days as required by law.

Please note that if your records are being mailed, it may take a few additional days for them to arrive. If you have requested to have your records emailed to yourself or another entity, the provided email address will receive a secure, password protected link to your records. For security purposes, this link will expire, so please be sure to check your email regularly, and always check your spam folder!

Is there a charge for the records?

Records sent to another provider are complimentary. There is no charge to have your records emailed or faxed to you. If you request that your medical records be mailed there is a charge for postage and processing.

CHI Health and CHI Health Clinic have partnered with Datavant and MediCopy services for the release of protected health information (PHI), otherwise known as medical records. Your medical record includes, but is not limited to your medical history, diagnosis, treatment as well as lab results and reports from previous testing and procedures.

To request a copy of your medical records, we ask that you fill out an authorization. You can complete an authorization by following one of the options below. If the patient is a minor, or unable to sign an authorization, the signature of an authorized legal guardian is required. Once your authorization is submitted, please allow two business days before calling to check status.

Rural clinics

• CHI Health Lenox Clinic – Lenox, IA
• CHI Health Corning Clinic – Corning, IA
• CHI Health Woodbine Clinic – Woodbine, IA
• CHI Health Bedford Clinic – Bedford, IA
• CHI Health Missouri Valley Clinic – Missouri Valley, IA
• CHI Health Dunlap Clinic – Dunlap, IA
• CHI Health Logan Clinic – Logan, IA
• CHI Health Howells Clinic – Howells, NE
• CHI Health Clinic - St. Mary's – Nebraska City, NE
• CHI Health Plainview Clinic – Plainview, NE
• CHI Health Schuyler Clinic – Schuyler, NE
• CHI Health Clarkson Clinic – Clarkson, NE

Electronic Request for Records

Patients can request medical records electronically through an online patient record request tool that verifies your identity by asking for a photo of your driver’s license, which can be taken via webcam or smartphone. If questions, contact a hospital release of information representative at (402) 717-1799.  Please note: Chrome, Safari and Firefox are the recommended browsers for this application.

Request records by completion of authorization form or patient access request form

Request your medical records by downloading, printing and completing the “Authorization for Use or Disclosure of/Access to protected health information” form (to authorize disclosure of records to another person or organization) or “Patient access request to their protected health information” form (to request access to own records).  Select "Other" and list the clinic from which you are requesting records. 

If questions on completing the form, contact the release of information representative at 402-717-1792 for assistance.

Authorization for use or disclosure of/access to protected health information form

• Medical records request and authorization

Patient access request to their protected health information form

• Patient access request

Submit the form by any of the following methods:

1. Bring form to the clinic to submit for processing
   
   
2. Fax the form to (402) 818-1567 Attn: Release of Information
   
   
3. Mail the form to:
   CHI Health Medical Records
   Attn:  Health Information Management (Release of Information)
   7500 Mercy Rd
   Omaha, NE 68124-2398
   
   
4. Email form to:  [email protected]
   

Medical Record Copy Fees

• For records sent directly to a provider or other health care facility for continuing care, there is no fee.
• For patients only, below are the standard fees to produce a copy of your medical records. In some states patients may receive nominal pages for free based on the lower of a state or federal rate.
  
  • Electronically maintained records delivered in electronic format $6.50
    
  • Electronically maintained medical records combined with paper records delivered in Electronic format are billed at $6.50 (for the electronic portion) + $0.09 per page (for the paper portion) for labor involved in creating an electronic copy of the records maintained on paper
    
  • Electronically maintained records delivered on paper are $1.15 for labor cost to create the paper copy of the record maintained electronically plus $0.06 per page for paper and toner
    
  • Paper records delivered in electronic format are $0.09 per page for the labor involved in creating an electronic copy of the records
    
  • Paper records delivered on paper are $0.15 per page
    
• Plus, postage and applicable taxes

Processing your request

• In most cases, record copies are available in less than a week, however some requests may take longer to process.
• If you have questions or need to verify the status of your submitted request, please contact the facility at the above phone number.