Review Us

Des Moines: (515) 255-3181Ankeny: (515) 964-2159
Make A Payment

Authorization to Release or Obtain Medical Information

Release/Obtain Medical Information

Patient Name(Required)
MM slash DD slash YYYY

Medical Provider

(From where are your records originating)
Address(Required)

Requestor

(Where do you want your information sent)
Address(Required)

Processing Information & Fee

When we transfer your records out to another clinic, we incur staff and material costs at the rate of $15/child or $30/family. Please submit payment with the records transfer request and please allow 7-10 business days for processing.
Complete History & Physical, Diagnostic Testing & Results, Immunization Records, Correspondence with Other Physicians, Other (please specify below)

Purpose for Release

When we transfer your records out to another clinic, we incur staff and material costs at the rate of $15/child or $30/family. Please submit payment with the records transfer request and please allow 7-10 business days for processing.
Specific authorization for release of information protected by state or federal law:(Required)
I specifically authorize the release of data and information relating to: (check off all that apply)

Authorization

The authorization is effective for one year from the date on which it was signed. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to the Des Moines Pediatric and Adolescent Center Medical Records Department.(Required)

Prohibition on Redisclosure

This form does not authorize redisclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. PART 2) and state requirements (Iowa Code Ch. 2288) prohibit further disclosure without specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosures of alcohol/drug abuse or mental health information.