Release of Information Request

Medical Record Requests

HIPAA regulations allow you to review, on request, a copy of your medical record and/or receive a copy of your medical record for reasonable copying charges.

  • All requests and copies for medical record information must be received in writing by using our Authorization to Disclose Protected Health Information form. If the patient is a minor, a parent or legally qualified* guardian must sign. The release form must be filled out in its entirety and signed in order to be processed. Return to us via email or PO Box 359, Manchester, IA 52057.
  • Medical records will be sent within 30 business days if the form is completed in its entirety. There may be a minimal fee for a request for records in order to cover copying costs.
  • *What it means to be legally qualified
    Written consent of the patient or his/her legally qualified representative is required for release of information from the medical record. Legally qualified representative is defined as guardian of a minor child or a person possessing Power of Attorney status or Executor of Estate status, with verification of such status.