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 appropriate 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.
Request for Release of Personal Health Information to Yourself
Request for Release of Personal Health Information to A Third Party
Please mail the form to:
Health Information Department
CHI Health St. Francis
P.O. Box 9804
Grand Island, NE 68802
If you have questions, please call our health information department at (308) 398-5658.
X-rays and Other Images
To request copies of X-rays, CT scans, or other images, please call the radiology department at (308) 398-5674. All images will be placed on a CD and can be mailed to your doctor or given to you to take to your doctor’s appointment. Whenever possible, please call 24 hours in advance to allow us time to prepare the images you need.
When picking up the images, you will need to sign an authorization form allowing us to release your information.
Complete information on obtaining copies of birth certificates of babies born at our hospital is available through the Nebraska Department of Health and Human Services website.
For additional assistance, you may contact:
Nebraska Department of Health & Human Services
Attn: Division of Public Health
P.O. Box 95065
Lincoln, NE 68509-5065
Phone: (402) 471-2871