Medical Records Request Form

Medical Records Request Form for Clients and Guardians
Our records request fee is based on Iowa law, which permits providers to charge reasonable, cost-based fees for copying and producing records, including staff time required to retrieve and prepare them. A flat fee of $35 reflects the typical administrative and production costs associated with fulfilling these requests and is consistent with allowable ‘reasonable expenses’ under Iowa Code § 22.3.
Name of Client*

First NameLast Name
Date of Birth

MonthDayYear
Date
Client completing requestGuardian Completing Request
Name of Guardian*

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
All RecordsTreatment PlanProgress NotesIntakes/AssessmentsMeasuresSpecific Dates:
If specific dates: (DOS) Date to Date (DOS).
In person pick up in Grundy CenterMailEmailFax
Address (If requested by mail)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (if requested)
example@example.com
Fax number (if requested)
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Request
I understand
Yes
Please verify that you are human*
Should be Empty:

Medical Records Request Form for Clients and Guardians