Medical Record Release Form

How to Obtain Medical Records from CMC Health Information Management Department

  1. Complete a form:  AUTHORIZATION FOR RELEASE (DISCLOSURE) OF INFORMATION.  This form can be printed from CMC website or you can contact the Health Information Management Department at CMC to request a paper form (402-245-6550). A properly executed release of information form should;
    1. Be addressed to the facility (Releaser)
    2. Designate the name of the person, company or agency to which the information is to be given or released to
    3. Specify the period of time or date of service for which information is being requested
    4. Be signed by the patient or legally qualified representative
    5. Make sure the release is dated at the time of, or after the hospital encounter for which information is being requested
  2. If information is for a minor (age 19 or under) an authorization must be signed by the parent and/or legal guardian in the case of a court ordered guardianship
  3. If information is for a deceased patient, authorization must be signed by the patient’s Power of Attorney, personal representative (the executor or administrator of the patient’s estate), spouse, or next of kin with proper identification.
  4. All requests for copies of medical records requires a 24 hour notice
  5. In some instances a fee will be charged for copies of records

Medical Records

How to Obtain Your Medical Records:

  1. Download and print this form.  Alternately you may contact us at (402) 245-6550 and request a Release of Medical Records Form.
  2. Mail or Fax this form to: Community Medical Center
    Health Information Management
    3307 Barada St., P.O. Box 399
    Falls City, NE 68355
    Phone: 402-245-6550
    Fax: 402-245-6650

If you need to obtain a copy of a legal birth certificate for a birth that occurred at Community Medical Center please visit the website: or contact DHHS Vital Records Department, P.O. Box 95065, Lincoln, NE  68509-5065.

CMC cannot provide medical advice over the phone.  Please contact your provider or schedule an appointment to receive test results, advice, a diagnosis or treatment.