Request to Obtain Confidential Information

Request for Release of Confidential Information

221 E. COLLEGE ST. STE 212 IOWA CITY, IOWA 52240 PHONE: 319-338-5190 FAX: 319-354-3718
Patient/Client Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The entity below is authorized to release information from their records:
Entity or Provider to Release Information*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Fax
Provider's Email
example@example.com
Purpose of Request to Release Confidential Information:*

For further medical evaluation, treatment, or careFor Consultative-Coaching in ProfessionalismOther
The information to be disclosed is marked below, concerning the time between
Start Date and End Date orPresent/Ongoing Care .
Information to be released:*

Hospital admission and discharge summariesMedical or Mental Health EvaluationsLabs, RadiologyMedical progress notes and treatment plansPerformance Reviews, Complaints, InterventionsJob Description, Employment RecordsOther
Please forward copies of requested records to Enter your provider's name *at Virtue Medicine P.C., 221 East College St. Ste 212, Iowa City, IA 52240. Phone: 319-338-5190. Fax 319-354-3718
Please release information in following conditions (if applicable):
If medical coordination of care, HIV-related and drug/alcohol information in the medical records are authorized for release unless indicated here:

Do not release HIV informationDo not release drug/alcohol information
I have had explained to me and fully understand this request/authorization to release records and information, including the nature of the records, their contents, and the likely consequences and implications of their release. I release the source of the records from any and all liability incurred through release of my records. This request is entirely voluntary on my part. I understand that I may revoke this consent at any time except to the extent that action based on this consent has already been taken.

This consent will expire automatically in 2 years, or Expiration Date , unless revoked in writing. I agree that a photocopy of this form is valid, if signed by client or legal guardian.
Printed name
Signature of client*

Clear
Today's Date*

MonthDayYear
Date
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Request for Release of Confidential Information