Form 1989 Hospital Admin Consent To

Form 1989 hospital admin consent to

File Name: consent-to-release.pdf

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Form 1989 Hospital #:
University of Iowa Health Care (UIHC)
Health Information Management Department, Release of Information Office, 200 Hawkins Dr., Iowa City, IA 52242
Telephone: 319-356-1719; Fax: 319-356-3079 or 319-353-7944; Email: [email protected]
Patient legal name: Birth date:
Complete mailing address:
List any previous names (maiden, married, legal changes):
Send UIHC information to: Myself at the address above unless noted below
Name and/or facility:
Complete mailing address:
Format of information to be released:
Electronic (circle): CD / USB drive / MyChart Verbal To file only Paper
Fax: Email:
(Email is not a secure means of communication)
Information to be released (will be from the previous two years unless specified below):
Summary of record Immunization record Pathology slides
Billing information Laboratory results Psychotherapy notes
Discharge notes Office visit notes Radiology images
Emergency notes Operative/Procedure reports Radiology reports
History and physical Pathology reports Test results (EKG, PFT, EMG, etc.)
Date(s): to and/or Department/Provider:
Reason for release:
Rehab/disability Insurance Legal Personal Medical Other:
This consent is voluntary. If I cancel this consent at a later date, I must send written notification to the Director of Health
Information Management at the above address. If this consent is cancelled, I understand that information may have been
released prior to the cancellation, and that action would not be considered a breach of confidentiality. I also acknowledge
that: 1) recipients of this information may possibly re-release the information without proper authorization, and 2) once
information is disclosed it may no longer be protected by federal privacy regulations. I understand that I may review the
disclosed information or ask questions by contacting the Director of Health Information Management at the above address. I
have been offered a copy of this authorization. I understand there may be a charge for this information

UIHC does not require completion of this form as a condition of evaluation or treatment. However, when the requested
evaluation or treatment is solely for the purpose of creating a medical report for a third party, if authorization to release the
information to that third party is not provided, it may result in the cancellation of those services. I understand that the
information may be released electronically, and may include information in the following categories unless I specifically deny
the release (check any category not to be released)

Substance abuse* Mental health HIV-related information Genetic tests/info**
*Information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2 prohibits unauthorized disclosure of these
records). **Refers to genetic testing to screen for possible future health issues, does not refer to testing to diagnose or treat current health conditions

This agreement allows release of past and future UIHC information and will expire 2 years from the date of signature, or as
indicated (specify number of days or months) ___________________________ unless cancelled by the patient/guardian

UIHC will respond to this request within 30 days of receipt. If additional time is required, you will be notified of the extension

Signature: Date:
(Patient or person legally authorized to consent for patient)
(Printed name of legally authorized person signing) (Relationship of legally authorized person)
(Witness signature, only required when patient or person legally authorized is physically unable to sign)
Internal use only: Initial if form has been processed and scanned into Epic under the HIM ROI Authorization document type

Revised: 8-2021

ADMIN – CONSENT TO RELEASE OF INFORMATION AND RIGHT OF ACCESS REQUEST . University of Iowa Health Care (UIHC) Health Information Management Department, Release …

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