Medical Record Forms
Consent to Release Form
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 firstname.lastname@example.org 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.