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 healthcare
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.
Consent to Release Information Form
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 the boxes
in front of the information you don’t want to be 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 to:
Health Information Management-ROI
Great River Health
1221 S. Gear Ave.
West Burlington, IA 52655
319-768-1970
HIMCustomerResourceTeam@greatriverhealth.org
Contact the Health Information Management team at
319-768-1900.
