Annual Financial Assistance Application

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Release of Information Form
As your health home, it is important for us to have access to all your health care records in order to provide you with the best quality of care.
  • Please print and fill out the Release of Information Form (ROI) liked at the top of this page if you need a copy of your medical or dental records.
  • The ROI must be filled out completely, signed, and dated by the patient, parent, guardian, or legal representative.
  • The request will not be honored if all required fields are not completed. Please Click Here for an example of how to fill out the form.

If you have further questions regarding this form, please call the Medical Records Department at (319) 874-3408 and speak with a Health Information Representative.