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Requesting Medical Records

Private Patient Information–Medical Records

Our core values ensure that we maintain the confidentiality of your personal and medical information in accordance with Health Insurance Portability and Accountability Act (HIPAA). If you would like a copy of your medical record, please contact our Health Information Management department by dialing 308-865-7945, or extension 7945 on the hospital campus phones.

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.

 Release of Information Form

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.