Consent to Obtain Information

CONSENT TO OBTAIN INFORMATION

University of Iowa Hospitals and Clinics

Hosp. #:

Please PRINT (except signatures) and provide complete answers (information) in each section.

Patient’s Legal Name Birth Date

I, the undersigned, hereby authorize: to release medical information concerning the above named patient to:

Name of Person and/or Institution

Complete Mailing Address/Street/P.O. Box

City, State, Zip Code

Check the information to be disclosed (include dates where indicated): Minimum necessary or specify:

Medication list     Allergy list     Immunization record     Problem List (Patient Summary List)

Most recent history and physical or specific date(s)

Most recent discharge summary or specific date(s)

Laboratory results, specify types or dates

X-ray and imaging reports, specify types or dates

Consultation reports from (doctors' names or clinic)

Test results (i.e. EKG, PFT, etc.), specify type and date

Billing Information

Other, specify:

Please indicate the reason for release, and provide a date by which the info is needed:

Insurance    2nd opinion    Rehab/disability    Personal file    Moving out of area    Legal

Other medical care    Transferring care

This authorization is voluntary. If I choose to cancel this consent at a later date, I must send written notification to the Director of Health Information Management, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242. 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.

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 (initial any category not to be released).

Substance Abuse     Mental Health     HIV-related information     *Genetic tests/info

*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 will expire one year from the date of signature, or as indicated (specify number of days or months) unless cancelled by the patient/guardian.

UIHC use only: Form mailed by

Date Name Department

Gray – To Be Mailed    Pink – Medical Record

Green – To Be Mailed, Then Returned to UIHC With Requested Information    Yellow – Patient (Required)

Revised 8-2011