Request Records

If you would like to request a copy of your records, please submit the Authorization for Release of Information form below. We will check our records and contact you.

I, , Date of Birth: , give permission to the Urgent Care Clinic of Lincoln, P.C. to:
Use the following protected health information, and/or

Disclose the following protected health information to:
*If records being sent to provider or insurance we need the fax number.

Information to be disclosed (check all that apply):

This protected health information is being used or disclosed for the following purposes:

If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulation, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations.

You may revoke this authorization in writing at any time by sending written notification to the Urgent Care Clinic of Lincoln, P.C. at 4210 Pioneer Woods Drive Suite A, Lincoln, NE 68506. Your notice will not apply to actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization.

By clicking the Submit button, Urgent Care Clinic of Lincoln has permission to print out your requested medical records. In order for UCCL to release the records to you, your signature is required. If the patient requesting his or her medical records is a minor, the Parent or Legal Guardian's signature is required. Please allow 24 hours for your medical records to be prepared and ready for pickup. Proof of identification will be required.
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