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
If you have any questions, contact the Health Information Management team at
319-768-1900.