CONSENT TO RELEASE MED RECORD TO PROVIDER

Consent to Release Medical Information
PATIENT
DATE OF BIRTH

MonthDayYear
Phone Number
Format: (000) 000-0000.
I hereby request that my medical records be released from:

Iowa Radiology

12368 Stratford Drive

Clive, Iowa 50325
Please send my records to: (Physician, hospital, or facility name)
Doctor/Facility:
Phone
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
Address
Address, City, State, Zip Code
Information Requested
Date of Service

MonthDayYear
Date
Date of Service

MonthDayYear
Date
Please list additional Dates of Service, if necessary:
This authorization will expire one year from the date of signature, except as specified.
Specify # of days or months
At this time, no express revocation shall be deemed to terminate my consent, but I understand that I may revoke this authorization at any time by sending a written notice to Iowa Radiology 12368 Stratford Drive, Clive, Iowa 50325. I understand that any release which was made prior to my revocation in compliance with this authorization, shall not constitute a breach of my rights to confidentiality. I understand that I may review the disclosed information by contacting Iowa Radiology.
Signature of Patient or Legal Guardian
Date

MonthDayYear
Date
Relationship, if not patient
Specific Authorization for Release of Information Protected by State or Federal law. I specifically authorize the release of data and information relating to: Check the appropriate box:
* For the above information to be released, you must sign here & check the appropriate box.
SIGNATURE
DATE

MonthDayYear
Date
sysAccountName
sysAppointmentID
sysOrderID
sysPatientID
sysCareflowPrefillID
userrole
sysUserName
Should be Empty:

Consent to Release Medical Information

Please send my records to: (Physician, hospital, or facility name)

Information Requested