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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. Privacy Notice (HIPAA)
  3. Receipt of Privacy Practices
  4. Release of Information and Guarantee of Payment
  5. Patient Info Sheet for Satellite Clinic
  6. Dr. Mahalek Patient Questionnaire
  7. Handicapped Parking Permit
  8. Authorization to Disclose Health Information

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

Download Adobe Reader

2810 West 35th Street • Kearney, NE 68845 • Phone: 308-865-2570 • Toll Free: 1-800-408-1689 • Fax: 308-865-2508

Also serving the following communities: Lexington, Holdrege, Arapahoe, Imperial and Gothenburg

Copyright © 2012 | Disclaimer
Last Modified: April 12, 2012