Form Center

2. Client Access to Records Request
   Fill out the information completely, including full mailing address. Your records will only be available via US mail and you MUST submit a valid State ID or driver's license along with this request. If you have questions, please call 402-441-6328
4. Patient Name
5. Other Name Used
7. Address
8. Date of Birth
10. City
11. State
12. Zip Code
14. Phone Number
15. Last 4 of SSN
16. E-mail Address
18. I am asking for access to my information for the following time period:
20. From:
21. To:
23. I understand that the County has thirty(30) days after receipt of this request to respond unless the requested information is off-site, in this case the response time is sixty(60) days. In addition, the County may notify me in writing that an extension of up to thirty(30) days is needed. I understand I will be responsible for the cost associated with copying or summarizing my health information. Fees will be reasonable and cost-based, and include only the cost of copying and/or postage.
25. I understand that I may be denied access to certain health information, including (1) information that is not held in the designated record set; (2) psychotherapy notes; (3) information compiled in reasonable anticipation of litigation; and (4) other information not subject to the right to access information under state or federal law.
27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
31. Signature of Patient/Client or Legal Representative
32. Today's Date
    Today's Date
34. Photo ID Upload*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field