Medical Information Release Form

Medical Information Release Form

Sensory Kids Therapy Services
Client's Date of Birth*

MonthDayYear
Date
Client's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Fax Number
Please enter a valid fax number.
Information To Be Released*

Initial Evaluation ReportsDischarge SummariesProgress notes (daily SOAP notes)Billing recordsPlan of care (treatment plans)Re-evaluation reports
Purpose Of This Release*

Personal ReferenceShare With Another ProviderInsurance PurposesLegal MattersSchool or IEP Planning
Delivery Methods (charges may apply)*

MailFaxScheduled Pick UpEmail
Acknowledgment of Fees for Records Request
I understand that, in accordance with Iowa Administrative Code r. 876-8.9 (Exchange of Records – Fees), a reasonable fee may be charged for the preparation and release of medical records. *

I acknowledge and agree to pay any applicable fees associated with this request.I do not agree to pay fees and understand that my request may not be processed.
* Please Note: Once this form is completed and submitted, our office will review the request and provide you with an estimate of any applicable fees prior to processing the release of records.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list the specific dates of records you would like disclosed
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Processing Timeline

Our goal is to process and fulfill record requests within 2 weeks of receiving a completed form and any required fees. However, under Iowa law, our office is permitted up to 30 days to prepare and release medical records.

To help us avoid delays and complete your request as efficiently as possible, please ensure that all sections of this form are fully completed and that any applicable fees are paid promptly.
Expiration: The authorization for the release of records is good for one year.
Date*

MonthDayYear
Date
Signature*

Clear
If the signature other than the client, please complete following areas. The signature belongs to:*

ParentLegal Guardian
Name*

First NameLast Name
5 E. Cherry Street North Liberty, Iowa 52317

Phone: 319-626-2257 Fax: 319-359-4015 info@sensorykidsiowa.com
Should be Empty:

Medical Information Release Form

Acknowledgment of Fees for Records Request

Processing Timeline

5 E. Cherry Street North Liberty, Iowa 52317