HIPAA Request Form

HIPAA Request Form -Med Rec Req.

This form will be used as a Release of Medical Records, Request Amendment to Health Information, Request for Accounting of Disclosures of Health Information, Registering a Privacy Complaint, Right to Request Restrictions, and Right to Request Confidential Communications.

Please complete and fax back to 402-465-9011 or mail to:

Gastroenterology Specialties
4545 R Street
Lincoln, NE 68503


If you have any questions about this form please call 402-465-4545 and request that a Medical Records staff member return your call.