Medical Records

Your medical record is confidential and may not be released without your consent.

Information concerning health care and medical services is maintained in a personal record retained at the Clinic. Medical information is available to the Clinic’s providers via the Clinic’s electronic health record and/or through the historical paper record. This ensures that each Clinic provider who sees a patient will have appropriate access to current and past information regarding medical diagnoses and treatment.

Online Medical Records Request

Click here to start your online request.

Release of Medical Information:

For information regarding the release of medical information, please call 563-584-3207, and select option 2.

Forms

Authorization to Release to a 3rd Party

This form can be used for:

- Family member for future needs.
- Records being released to another facility.
- Records coming to us from another facility.

Authorization Form to Release Information [PDF]

Patient Request to Access

- Not to be released to another person.
- Records go directly to the patient.

Patient Request Form to Access[PDF]

Disclose Exchange

Used when a patient designates a person(s) we may speak with verbally.

- Preferred: One form per person.
- Allows staff to talk with the designated individual.
- Not for releasing written records.

Authorization Form to Disclose Exchange [PDF]