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Consent to Release Information

How to Get Medical Records Medical records are protected by the Health Insurance Portability and Accountability Act (HIPAA). To get copies of your medical records for yourself or a health care provider who is not part of Great River Health, please print the Consent to Release Information form on this page and follow the directions below. If you have questions, call Health Information Management at 319-768-1900.

Required information

  • Patient’s full name and date of birth •
  • Check the box to identify where the information is to be released from – hospital or clinic. If it is a clinic, provide the name of the clinic.
  • Facility, entity or person to whom the information is to be sent
  • Address where the information is to be sent
  • Type of information requested and date(s) of service
  • Reason for the request • Under “Specific Authorization for Release of Information Protected by State or Federal Law,” check boxes in front of information you don’t want released.
  • Sign and date the form.
  • Relationship if you are not the patient:
    • Children under 18 years old – A parent must sign unless the law requires the minor’s consent.
    • Another person – If you have questions about who can sign for another person’s records, call Health Information Management.

Optional information

  • If the record format – paper or electronic – is not chosen, an electronic copy will be provided.
  • Include the signing person’s address and a witness’ signature.

You can mail, fax or email the complete form.

Mail:

Health Information Management-ROI
Great River Health
1221 S. Gear Ave.
West Burlington, IA 52655

Fax:

319-768-1970

Email:

HIMCustomerResourceTeam@greatriverhealth.org

Consent to Release Information Form