Medical Records Authorization Forms
Faith Regional Health Services is committed to protecting your private medical information and has established processes in place for releasing medical records to our patients. If you need to obtain a copy of your medical records or need to request to have them sent to another healthcare facility, insurance company, attorney, or another individual, you must submit a completed, signed, and dated authorization form, located below.
Authorization for Release of Information Form - English
Complete, sign, and date this form.
Authorization for Release of Information Form - Spanish
Complete, sign, and date this form in Spanish.
Please fill out this release form clearly, legibly, and completely before submitting it for us to fulfill. We are required by federal HIPAA regulations to ensure that all sections of this release are legible and all information is complete. If the form is not filled out completely or legibly, it will be returned to you for resubmission once completed. Please include your contact phone number for us to call with any questions.
Before you submit the Form, Consider:
- If the patient is a minor, under the age of 19, the parent or legal guardian needs to sign the form. If the minor is emancipated, we will need you to supply us with the documentation to support this.
- If someone other than the patient is signing the release form, please provide us with documentation to support the signature (i.e. Power of Attorney papers).
- Please specify the types of records that you are requesting and indicate the method of delivery you would like to receive the forms.
- If you would like our office to fax your medical records to your healthcare provider for an upcoming appointment, please provide us with a fax number.
If you have any questions while completing this form, please call our Health Information department at (402) 644-7602. Our office is open Monday-Friday from 8:00 a.m. - 4:30 p.m. You can also email us at email@example.com.
To Submit the Form
Once you have completed the release form, you can return the form using one of the methods below:
You can mail the form to our office at:
Faith Regional Health Services
Attn. Health Information
1500 Koenigstein Ave.
Norfolk, NE 68701
You can fax the form to us at (402) 644-7510
You can email the form to us at firstname.lastname@example.org.