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.
Request for Release of Personal Health Information
Please mail or fax the form to:
Health Information Department
CHI Health Good Samaritan
PO Box 1990
Kearney, NE 68848
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.