Medical Records Release Form - Lincoln Surgical Hospital

To submit the completed Medical Records Release Form, choose from one of the following methods: Fax the request to Medical Records at 402-484-9046. Mail the request to Lincoln Surgical Hospital, 1710 South 70th Street, Suite 200, Lincoln, NE 68506, ATTN: Medical Records. Hand the completed form to the front desk staff at Lincoln Surgical Hospital or Nebraska Surgery Center in an envelope labeled 'Attn: Medical Records.' Email the completed form to lshmedrec@lincolnsurgery.com. Ensure that all sections of the form are filled out completely and accurately to avoid processing delays. My advice is to double-check your information before submission and follow up if you haven't received confirmation within the specified timeline.

Important dates for this form in 2024 and 2025 include ensuring the authorization is signed within 60 days of submission. Additionally, allow 20 days for processing from the date the form is completed and received.

The purpose of the Medical Records Release Form is to authorize the release, transfer, or obtain copies of a patient's health records. This ensures that patients can manage their healthcare information effectively and transfer it securely to other healthcare providers or entities. By following the outlined steps and completing the required sections, patients and their representatives can ensure their request is processed without delay. Each record request must be authorized in writing, providing a safeguard for the privacy and confidentiality of patient records. The form allows a detailed specification of which records are needed, the preferred delivery format, and the designated recipient of the records. These options include receiving records electronically, on paper, or via a secured flash drive, making the process adaptable to varied needs. Understanding the importance of this form in the healthcare management process is essential for patients, lawful representatives, and other entities that require access to patient health information. Timely and accurate completion of this form facilitates efficient record handling, ensuring continuity of care and fulfilling legal or insurance-related requirements.

• 1. Name of Facilities: Specifies the names of the facilities involved - Lincoln Surgical Hospital (LSH) & Nebraska Surgery Center (NSC).
• 2. Address of Facilities Medical Records Department: The address where the request will be sent: 1710 South 70th Street, Suite 200, Lincoln, NE 68506.
• 3. Patient Name: The full name of the patient requesting or authorizing the records release.
• 4. Address: The residential address of the patient.
• 5. E-mail Address: The email address of the patient for contact purposes.
• 6. Action Requested: Indicate whether the patient wants a copy of their health record or wants to release it to another party.
• 7. Specific Records to Request: Select specific types of records requested or opt for the complete record.
• 8. Date(s) of Service: Specify the dates of the medical services relevant to the requested records.
• 9. Purpose: The reason for the records request, such as personal use, healthcare treatment, legal, or insurance purposes.
• 10. Format: Preferred format for receiving the records - paper, electronically, flash drive, email, fax, or certified mail.
• 11. Signature of Patient: The signature of the patient authorizing the request, along with the date.
• 12. Representative Signature: If not signed by the patient, the representative's signature and proof of authority to act on behalf of the patient.

Failing to submit this form correctly may result in delays or inability to process your request for medical records.

• Delayed Processing: Requests may be delayed if the form is incomplete or incorrect.
• Request Denied: Incomplete forms may be denied, requiring resubmission.
• Medical Care Interruption: Access to necessary medical records may be hindered, potentially impacting treatment.
• Legal Implications: In some cases, failure to provide required records can have legal consequences.
• Insurance Claims Issues: Insurance claims processing could be delayed without the proper records.

• 1. Personal Record Keeping: Request copies of your medical records for personal record-keeping.
• 2. Transfer to Another Provider: Authorize the release of records to another healthcare provider.
• 3. Legal Documentation: Obtain records required for legal purposes or litigation.
• 4. Insurance Claims: Provide necessary records for insurance claim processing.
• 5. Healthcare Continuity: Ensure continuity in healthcare treatment by transferring records as needed.