Welcome to our online medical records request form.  This form is to be used to request copies or information from your medical record or for someone you are the legal guardian for.

Fill in the patient information and a description of what you are requesting.  If you need copies of more than one patient’s medical records, you will need to fill out a different form for each patient.  If you have any questions call Thayer County Health Services at 402-768-6041 during normal business hours and ask to be connected to the health information office.

Important Reminder
This form is just a medical records request.  The Health Information office will verify the request and contact you by the method you indicated (phone or email) regarding your request.
You will need to attach a signed copy of a Records Release Request along with your online request. If you don’t have one here is a link to download one:  Records Release Request Form

Online Records Request Form, Updated March, 2023

  • Drop files here or
    Max. file size: 512 MB.
    • If you are making a request for medical records for a minor child or someone you are the responsible party for, you will need to put your name as the contact.
    • If you can not be reached during normal clinic hours, a valid email address should be listed to use to communicate with you.
    • Contact Phone Number. You should list a phone number where we can reach you during normal business hours.
    • Please provide us with details on what part of the patient's medical records you are requesting copies of or information about.
    • This field is for validation purposes and should be left unchanged.