enforce@iowa.gov
400 SW 8th Street, Suite B, Des Moines, IA 50309
515-281-6472
Authorization for Release of Medical Information
Patient's Name
Street Address
I, the undersigned, do authorize and request the listed Health Care Provider to release to the
Iowa Board of Nursing 400 SW 8th Street, Suite B Des Moines, IA 50309-4685.
The information is being disclosed and may be used for the purpose of a CONFIDENTIAL INVESTIGATION.
Business Address (Number & Street)
I agree that the Health Care Provider listed on this form may release the following information from these medical records:
Medical Records to Release (Click all that apply)
I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to the Iowa Board of Nursing and the above named Health Care Provider.
I understand that I have the right to inspect the information to be disclosed upon proper notification to and under appropriate conditions established by the above named Health Care Provider.
PROHIBITION ON REDISCLOSURE This form does not authorize redisclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by Federal Law for Alcohol/Drug Abuse Records or by State Law for Mental Health Records, Federal Requirements (42 C.F.R. Part 2) and State Requirements (Iowa Code ch.228) prohibit further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or Criminal penalties may attach for unauthorized disclosure of Alcohol/Drug Abuse or Mental Health Information.
Sign Here (Patient or Patient's Authorized Representative)
