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Authorization for release and disclosure, and/or request for medical information and records – IOWA

This online form is for Pine Rest TELEHEALTH patients only.

If you are a Pine Rest INPATIENT or PARTIAL HOSPITALIZATION patient, please use the Hospital Release of Information form.

If you are a Pine Rest patient or receiving treatment AT AN OUTPATIENT CLINIC IN IOWA, please use the printable Release of Information form for Iowa and bring it to the clinic.

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