Release of Information Form

Request for Authorization For Disclosure of Health Information

With any questions, please contact Medical Records at 712-542-8302. Clarinda Regional Health Center Information: 220 Essie Davison Drive, Clarinda, Iowa 51632. Phone Number: 712-542-8302. Fax Number: 712-542-8346.
DateTime
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Release Information From:
Person and/ or Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax*

Area CodePhone Number
Release Information To
Person and/ or Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax*

Area CodePhone Number
Continuing CareChanging ProviderMovingDischarge SummaryInsuranceMilitarySchool
All Medical RecordsProvider's NotesEmergency Room ReportsRadiology StudiesHistory and PhysicalEKG'sOperative ReportLab ReportsDischarge SummaryOther
Include alcohol/drug treatment records protected under 42 CFR Part 2Do NOT release alcohol/drug treatment records
Redisclosure Warning (42 CFR Part 2): This information has been disclosed from records protected by federal confidentiality rules. Further disclosure is prohibited unless expressly permitted by written consent or as allowed by law.
Include HIV/AIDS testing and/or treatmentDo NOT release HIV/AIDS records
Iowa Law Notice: Under Iowa Code §141A.9, HIV-related information is strictly confidential. The recipient may not disclose this information to others without specific written consent. General medical authorization is insufficient for HIV records. Raw psychological test data may only be provided to a licensed healthcare provider as defined by the Iowa statute.
Psychiatric EvaluationPsychological EvaluationClinical Intake EvaluationWritten Report Regarding TreatmentProgress NotesOther
AllRange (Input Dates)
Start Date*
Jan. 1, 2018
End Date*
Dec. 31, 2028
The following person(s) has permission to pick up my medical record:
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Relationship to Patient
If you are filling this out for yourself, type SELF
Please verify that you are human*
ELECTRONIC SIGNATURE & IDENTITY VERIFICATION
If this authorization is submitted electronically, the patient or authorized representative acknowledges and agrees that:
1. Electronic signatures are legally valid and equivalent to handwritten signatures.
2. The releasing facility may verify identity using secure authentication methods, including but not limited to:Confirmation using contact information already on file
3. Records will not be released until identity and authority are verified.
4. The facility reserves the right to request additional identification if necessary to protect patient privacy.
I understand that submission of this form does not guarantee release of records until my identity and authority are verified.
Patient or Authorized Representative Electronic Signature

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Request for Authorization For Disclosure of Health Information

Release Information From:

Release Information To

The following person(s) has permission to pick up my medical record:

ELECTRONIC SIGNATURE & IDENTITY VERIFICATION