Fill out this secure form at least 48 hours before the appointment and reduce wait time when you arrive in clinic.
This form along with other financial documents will determine your ability to pay for services you receive from UNMC Physicians. Patients must demonstrate an inability to pay for non-elective, medically necessary services.
Release of Information
Fill out and mail this form to request that your medical information be released. You may fill in the blanks and then print and sign it, or fill all of it out by hand. The authorization must be completely filled out. Failure to do so may delay the release of your medical information. Incomplete or partially completed requests cannot be processed and will be returned for complete information.
You may submit your completed release of information authorization form by mail or by fax. Please remember that incomplete forms cannot be processed and will be returned to the requestor.
To submit your completed release of information form by mail:
Health Information Management– Release of Information
The Nebraska Medical Center
10304 Crown Point Ave
Omaha, NE 68134
To submit your completed authorization form by fax:
Attention HIM– Release of Information - The Nebraska Medical Center
More about your medical records