"Consent to Release Information" - Iowa

Consent to Release Information is a legal document that was released by the Iowa Department of Corrections - a government authority operating within Iowa.

Form Details:

  • Released on February 1, 2020;
  • The latest edition currently provided by the Iowa Department of Corrections;
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IOWA DEPARTMENT OF CORRECTIONS
IOWA DEPARTMENT OF CORRECTIONAL SERVICES JUDICIAL DISTRICTS
Consent to Release Information
___________________________________
_______________________
___
______________
____/____/______
Patient/Client Last Name
First Name
MI
ICON No.
Date of Birth
I authorize the [ ] Iowa Department of Corrections [ ] the Iowa Department of Correctional Services Judicial Districts
____________________________________
__________________________________
_____
_________
Address
City
State
Zip
[ ] To obtain records and information noted below, in oral, written, electronic, or other format from
agency/organization/individual(s) listed below
[ ] To release records and information noted below, in oral, written, electronic, or other format to
agency/organization/individual(s) listed below
_______________________________
_____________________________________ ________________ _____ _________
Agency/Organization/Individual
Address
City
State
Zip
Types of information (check all that apply):
Specific Authorization
[ ] Medical
For Information Protected by State or Federal Law
[ ] Hospital
I specifically authorize the release and disclosure of records and
[ ] Psychiatric
information about my (check and initial all that apply)
[ ] Psychological
1. Substance Use
[ ]
______
[ ] Substance Use or Treatment
Initials
[ ] Discipline and Time Computation
2. Mental Health
[ ]
_____
[ ] Other (specify): __________________________
Initials
3. HIV/AIDS Related Information
[ ]
_____
For the following purposes (check all that apply):
Initials
[ ] Treatment
4. Genetic Testing
[ ]
_____
[ ] Supervision
Initials
[ ] Public and Private Benefits Programs
5. Developmental Disabilities
[ ]
_____
[ ] Employment
Initials
[ ] Housing
6. Sexually Transmitted Diseases
[ ]
_____
[ ] Referral
Initials
[ ] Other (specify): _________________________
_____________________________________
________
Patient/Client/Legal Guardian Signature
Date
I understand that my protected health information, as well as records and information about my substance use, mental health,
HIV/AIDS, and genetic testing are protected under the federal regulations governing Confidentiality of Substance Use Disorder
Patient Records (42 C.F.R. Part 2), the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160
& 164, and by Iowa Code Chapter 228 regarding Mental Health and Psychological Information, and cannot be disclosed without my
written consent unless otherwise provided for in the regulations. I may revoke this consent at any time. I may request to inspect
disclosed health information by providing written notice to the Iowa Department of Corrections or the Iowa Department of
Correctional Services offices. Any release of information or records which has been made prior to my revocation, and which has
been made in reliance upon this authorization, shall not constitute a breach of my rights to confidentiality.
I also acknowledge that
a) some recipients of this information may possibly re-release the information without proper authorization, and b) once information
is disclosed it may no longer be protected by federal privacy regulations or state law .
The Department of Corrections and Department
of Correctional Services may not require this form as a condition for treatment, payment, enrollment in a health plan, or eligibility
for benefits. However, when the provision of services is solely for the purpose of creating a medical report using protected health
information for a third party, refusal to sign may result in denial of those services. My consent will expire on ___/___/___ or at the
time my correctional supervision is completed.
__________________________________________________________________________________
Patient/Client/Legal Guardian Signature
Date
Witness Signature
Date
Replaces: HSF-304A & AD-CR-04 F-2
Origination Date: Feb. 2012. Reviewed: Aug. 2013, Feb. 2014. Revised: Nov. 2014. Reviewed: April 2015, Oct. 2016.
Revised: July 2017, May 2018. Reviewed: July 2018, May 2019, Feb. 2020.
AD-CR-04 F-2
 
IOWA DEPARTMENT OF CORRECTIONS
IOWA DEPARTMENT OF CORRECTIONAL SERVICES JUDICIAL DISTRICTS
Consent to Release Information
___________________________________
_______________________
___
______________
____/____/______
Patient/Client Last Name
First Name
MI
ICON No.
Date of Birth
I authorize the [ ] Iowa Department of Corrections [ ] the Iowa Department of Correctional Services Judicial Districts
____________________________________
__________________________________
_____
_________
Address
City
State
Zip
[ ] To obtain records and information noted below, in oral, written, electronic, or other format from
agency/organization/individual(s) listed below
[ ] To release records and information noted below, in oral, written, electronic, or other format to
agency/organization/individual(s) listed below
_______________________________
_____________________________________ ________________ _____ _________
Agency/Organization/Individual
Address
City
State
Zip
Types of information (check all that apply):
Specific Authorization
[ ] Medical
For Information Protected by State or Federal Law
[ ] Hospital
I specifically authorize the release and disclosure of records and
[ ] Psychiatric
information about my (check and initial all that apply)
[ ] Psychological
1. Substance Use
[ ]
______
[ ] Substance Use or Treatment
Initials
[ ] Discipline and Time Computation
2. Mental Health
[ ]
_____
[ ] Other (specify): __________________________
Initials
3. HIV/AIDS Related Information
[ ]
_____
For the following purposes (check all that apply):
Initials
[ ] Treatment
4. Genetic Testing
[ ]
_____
[ ] Supervision
Initials
[ ] Public and Private Benefits Programs
5. Developmental Disabilities
[ ]
_____
[ ] Employment
Initials
[ ] Housing
6. Sexually Transmitted Diseases
[ ]
_____
[ ] Referral
Initials
[ ] Other (specify): _________________________
_____________________________________
________
Patient/Client/Legal Guardian Signature
Date
I understand that my protected health information, as well as records and information about my substance use, mental health,
HIV/AIDS, and genetic testing are protected under the federal regulations governing Confidentiality of Substance Use Disorder
Patient Records (42 C.F.R. Part 2), the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160
& 164, and by Iowa Code Chapter 228 regarding Mental Health and Psychological Information, and cannot be disclosed without my
written consent unless otherwise provided for in the regulations. I may revoke this consent at any time. I may request to inspect
disclosed health information by providing written notice to the Iowa Department of Corrections or the Iowa Department of
Correctional Services offices. Any release of information or records which has been made prior to my revocation, and which has
been made in reliance upon this authorization, shall not constitute a breach of my rights to confidentiality.
I also acknowledge that
a) some recipients of this information may possibly re-release the information without proper authorization, and b) once information
is disclosed it may no longer be protected by federal privacy regulations or state law .
The Department of Corrections and Department
of Correctional Services may not require this form as a condition for treatment, payment, enrollment in a health plan, or eligibility
for benefits. However, when the provision of services is solely for the purpose of creating a medical report using protected health
information for a third party, refusal to sign may result in denial of those services. My consent will expire on ___/___/___ or at the
time my correctional supervision is completed.
__________________________________________________________________________________
Patient/Client/Legal Guardian Signature
Date
Witness Signature
Date
Replaces: HSF-304A & AD-CR-04 F-2
Origination Date: Feb. 2012. Reviewed: Aug. 2013, Feb. 2014. Revised: Nov. 2014. Reviewed: April 2015, Oct. 2016.
Revised: July 2017, May 2018. Reviewed: July 2018, May 2019, Feb. 2020.
AD-CR-04 F-2