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 appropriate 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 to Yourself

Request for Release of Personal Health Information to A Third Party. 

Please mail the form to:

Health Information Department
Saint Francis Medical Center
PO Box 9804
Grand Island, NE 68802

If you have questions, please call our Health Information department at 308-398-5658.