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About Your Visit: Medical Forms

Provided below are various forms that require completion prior to your visit and/or surgery. Please download the appropriate form as directed by your physician and/or staff by clicking on the name of the form. If you cannot access the form, please click on the Adobe icon. This will allow you to download this software, providing access to the forms. Please bring the completed form(s) with you to your scheduled visit. This will help expedite the registration process. Thank you.

Medical Records

Patient Records
You may request a copy of your New West medical records or exam results. You must complete a Request Form and mail it to our clinic address with "Attn: Medical Records" on the envelope. You can also fax the form to us at 308-865-2508. The patient is not charged for the first copy. Subsequent requests and copies are $20 each.

There is a $20 charge to third parties (attorneys, agencies, and commercial insurances). Records are released to third parties only after the patient submits a Request for Release of Information.

Handicapped Parking Permits
If you need a Handicapped Parking Permit, print the Nebraska form and bring it with you to your appointment.

  1. Medical History
  2. 19 and Under Patient Parent
    Information Form
  3. HIPAA Notice of Privacy Practices
  4. Receipt of Privacy Practices
  5. Patient Info Sheet for Satellite Clinic
  6. Dr. Mahalek Patient Questionnaire
  7. Handicapped Parking Permit
  8. Authorization to Disclose Protected
    Health Information
  9. Foot / Ankle MRI Paperwork
  10. Hand / Wrist / Finger MRI Paperwork
  11. Knee MRI Paperwork
  12. Pelvis / Hip MRI Paperwork
  13. Shoulder / Elbow MRI Paperwork
  14. Spine MRI Paperwork
  15. Notice of Nondiscrimination and Accessibility /
    Aviso de No Discriminacion y Accessibilidad
  16. Section 1557 Taglines

Click here to complete your health history form securely online »

If you cannot access the forms you can click on the icon to download the software.

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