CONSENT TO RELEASE MED RECORD TO SELF

REQUEST TO SEND PROTECTED HEALTH INFORMATION TO SELF

As a patient of Iowa Radiology, you are entitled under federal law to request your personal protected health information for yourself. Please complete this form and a copy will be emailed to medrecords@iowarad.com. Once received, the information will be used to verify your identity, and your request will be processed.

Patient Name

Date of Birth

Patient Phone Number

Format: (000) 000-0000.

Date(s) of service

What type of exam(s)?

What type of records are you requesting?

How would you like to receive the information?

Where would you like it mailed?

Address, City, State, Zip Code

Which location would you like to pick it up?

I understand the revocation will not apply to information that has already been released in response to this authorization.

I understand that Iowa Radiology is given thirty days to process my request for access.

This authorization will expire one year from the date of signature.

By signing below, I acknowledge and agree to the above conditions.

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

DATE

Date

sysAccountName

sysAppointmentID

sysOrderID

sysPatientID

sysCareflowPrefillID

userrole

sysUserName