Patients & Visitors
Requesting Medical Records
How to Obtain Medical Records
If you are a current patient in the hospital, you may ask your nurse to provide you with a request form authorizing the release of your medical information.
If you are not currently a patient, you may print and complete the form below releasing your medical record to either yourself or to a third party such as an attorney, caregiver or life insurance company.
The form must be signed by a person of authorization of the released information, such as the individual patient, parent or guardian, or personal representative.
Please mail or fax the form to:
Health Information Department
CHI Health Good Samaritan
PO Box 1990
Kearney, NE 68848
Fax: (308) 865-2926
Please note: A fee may be charged for cost of copying records.
If you have questions, please call our Health Information Department at (308) 865-7945.