Patient Resources

Our patient resources section includes forms and policies you may need. Please click on the links below for additional information. Faith Regional Physician Services is dedicated to providing you the resources you need to make your visit as seamless as possible. 

For more information, please visit Patients & Visitors | Faith Regional Health Services | Norfolk, NE

Medical Records Authorization Forms

AUTHORIZATION FOR RELEASE OF INFORMATION          AUTORIZACIÓN PARA DIVULGAR INFORMACIÓN

Please fill out this release form clearly, legibly, and completely before submitting it for us to fulfill. We are required by federal HIPAA regulations to ensure that all sections of this release are legible and all information is complete. If the form is not filled out completely or legibly, it will be returned to you for resubmission once completed. Please include your contact phone number for us to call with any questions.

Before you submit the Form, Consider:

• If the patient is a minor, under the age of 19, the parent or legal guardian needs to sign the form. If the minor is emancipated, we will need you to supply us with the documentation to support this.
• If someone other than the patient is signing the release form, please provide us with documentation to support the signature (i.e. Power of Attorney papers).
• Please specify the types of records that you are requesting and indicate the method of delivery you would like to receive the forms.
• If you would like our office to fax your medical records to your healthcare provider for an upcoming appointment, please provide us with a fax number.

If you have any questions while completing this form, please call our Health Information department at (402) 644-7602. Our office is open Monday-Friday from 8:00 a.m. – 4:30 p.m. You can also email us at medicalrecords@frhs.org.