Medical Records Authorization (HIPAA) - Iowa

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (IOWA)

This Authorization complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. § 164.508, and applicable Iowa law.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following provider(s), facility(ies), and their business associates to release my protected health information ("PHI"):

3. RECIPIENT(S) — WHO MAY RECEIVE THE RECORDS

4. RECORDS / INFORMATION TO BE RELEASED

☐ Complete medical record
☐ Only records for the following date range: [__/__/____] to [__/__/____]
☐ Only records relating to the following incident/condition: [________________________________]

Record types (check all that apply):

☐ History and physical / office notes
☐ Physician and nursing notes
☐ Hospital / emergency-department records
☐ Diagnostic imaging (X-ray, MRI, CT) films and reports
☐ Laboratory and pathology results
☐ Operative and procedure reports
☐ Physical therapy / rehabilitation records
☐ Prescription and medication records
☐ Itemized billing statements and insurance records
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

This disclosure is made at the request of the patient for the following purpose: evaluation, investigation, prosecution, and settlement of the patient's personal-injury claim, including legal representation.

☐ Patient's waiver under Iowa Code § 622.10(3) (records relating to the condition alleged)
☐ Other purpose: [________________________________]

6. HIPAA CORE-ELEMENT RECITALS

6.1 Expiration. This Authorization expires on the earlier of: (a) [__/__/____]; (b) the following event: [final resolution of the personal-injury claim]; or (c) if no date or event is stated, two (2) years from the date of signature.

6.2 Right to Revoke. I may revoke this Authorization at any time by written, signed notice to the provider, except to the extent action has already been taken in reliance on it.

6.3 No Conditioning. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. Information disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Iowa law.

6.5 Copy. I am entitled to a copy of this signed Authorization.

7. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

8. IOWA § 622.10 PATIENT'S WAIVER ACKNOWLEDGMENT

☐ This Authorization is executed as a legally sufficient patient's waiver under Iowa Code § 622.10(3) and is limited to records relating to the condition alleged in the litigation captioned: [________________________________].

I understand that in a civil action in which my medical condition is an element or factor of a claim or defense, an adverse party may obtain records relating to the condition alleged, and that I must execute a legally sufficient waiver within sixty (60) days of a written request.

9. COPY FEES AND RESPONSE TIME (IOWA)

Iowa providers must respond to a properly executed records request within thirty (30) days, with a single written extension of up to thirty (30) additional days if compliance is not possible within the initial period. Under Iowa Code § 622.10, a provider that produces records or consults in connection with litigation may charge a reasonable fee for production (copies, diagnostic imaging, and consultation), with copy fees as specified in § 622.10(6). Mental-health information is governed by Iowa Code ch. 228, HIV-related information by Iowa Code § 141A.9, and SUD records by 42 C.F.R. Part 2 — each requires a separate authorization.

10. SIGNATURE

Personal representative (if patient is a minor, incapacitated, or deceased):

11. NOTARY (OPTIONAL)

State of Iowa, County of [________________]

Subscribed and sworn before me this [____] day of [____________], 20[____].

Notary Public: ________________________________ My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• Iowa Code § 622.10 — Communications in professional confidence; waiver; records and fees: https://www.legis.iowa.gov/docs/code/622.10.pdf
• Iowa Code ch. 228 — Disclosure of mental health information: https://www.legis.iowa.gov/docs/code/228.pdf
• Iowa Code ch. 141A — HIV-related test information (§ 141A.9 confidentiality): https://www.legis.iowa.gov/docs/code/141A.pdf