Patient Forms

Acknowledgement of Receipt of Notice Privacy Practice

This form grants permission for disclosure of medical information and acknowledges that you have received a copy of the Iowa Heart Center Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act of 1996.

Patient Portal Authorized Individual

This form grants an authorized individual access to a particular patients medical records via the patient portal. This form is required when requesting access to any adult or minor medical record.

Return your completed form to your local IOWA HEART CENTER OFFICE and your request will be reviewed by our medical records department. 

Patient Rights & Responsibilities

Release of Information

MercyOne Iowa Heart Center takes patient privacy very seriously and is dedicated to collecting, maintaining and providing quality patient health information. The Release of Information form must be completed and received by our medical records department prior to records being released. Any fields left blank may prevent or delay the process. Be sure to sign and date the form.

Note: If the individual signing the authorization form is a Guardian, Executor of the Estate or Power of Attorney for the patient, that person must submit a copy of the appropriate legal document, which proves authority to act on behalf of the patient. This must accompany the authorization form.

MercyOne Iowa Heart Center has partnered with MediCopy to fulfill your Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning release of medical information. Easily and electronically sign an authorization form online using the MediCopy website

A PDF version is also available and the completed form may be dropped off at your local Iowa Heart Center office or faxed to the release of information department at (515) 246-4485.

Please be aware that MercyOne Iowa Heart Center may impose a fee to cover costs involved in processing this release of information for purposes other than patient care. 

If you have questions, please contact our Release of Information department at (515) 633-3880.