Medical Record Forms

Consent to Release Form

A consent to release information form, also known as a medical record information release (HIPAA) form, enables patients to grant authorization for a third party to access their health records. It additionally provides the option for healthcare providers to share medical information. Importantly, individuals have the power to revoke or reassign these permissions at any time.

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Consent to Release Form

Consent to Share Form

The consent to share information form is essential in order to share medical information with family members or spouses. It serves as a crucial tool for reviewing and sharing an individual’s medical history while maintaining privacy and control over the information.

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Consent to Share Form

As a patient of Iowa Radiology, you are entitled under federal law to request your personal protected health information for yourself or provided to another individual. Please complete this form and submit it to or by fax at (515) 226-9812 along with a copy of a valid, state-issued photo ID. Once received, the information will be used to verify your identity and your request will be processed.

By sending this information you understand that any information sent by email is sent uncrypted, unsecured and accept those risks.