Request Patient Results

It is best for patients to reach out to their provider directly to obtain test results. If you would like to obtain a copy of your Results from Regional Pathology Services please follow the below guidelines.

The following people are authorized to sign for release of information:

• The patient (a spouse cannot sign unless they have legal authority).

• A person with Power of Attorney (POA) if the patient is unable to sign. A copy of the Power of Attorney document must be provided.

• A parent or legal guardian if the patient is under 19 years of age.

• A legal guardian. A copy of the guardianship documents must be provided.

• The personal representative of a deceased patient's estate. A copy of the death certificate and documentation showing appointment as the estate representative must be provided.

How to Complete the Authorization Form

Step 1: Enter Patient Information

Step 2: Select the Records Requested

Check the box or boxes that match the medical records or test results you are requesting.

Step 3: Enter the Date(s) of Service

Write the date(s) of service or the time period for the records you want.

Examples:  Office visit on 01/25/2008; All records from 2007–2008

Step 4: Choose How You Want to Receive Your Records

         • Mail     • Fax     • Pick up in person

If you mail or fax the completed authorization form:

• The signature must be notarized.
• Include a copy of a valid government-issued photo ID.

Step 5: Submit the Completed Form by One of These Options

      • Mail     • Fax     • Pick up in person

Step 6: Pick Up Records in Person During Office Hours |  Monday-Friday 8 am to 5 pm

Anyone picking up records must present a valid government-issued photo ID. If someone other than the patient will pick up the records, list that person's name on the authorization form.

Questions?  If you need help completing the form, please call: 402-559-6420  |  1-800-334-0459

Please allow up to 30 days to process your request.

Release of Medical Record Authorization Form