Our Responsibility
As your health care provider, we are legally required to protect the privacy of your health information, and to provide you with this notice about our legal obligations and privacy practices. This requirement applies to all patients served by University of Northern Iowa, Student Health Clinic. We will follow the privacy practices described in this notice. If you have any questions or want more information, please notify our Contact Officer.
Medical Record Release
You may request a release of your medical record to another provider or yourself. A consent form must be completed for this process. There are three opportunities to obtain this form: you can sign the form at the SHC, you can request a form be sent to you by calling (319) 273-2133 or you can down load the form on line and mail or fax the signed consent to the clinic.
NOTE: This form is NOT automatically submitted on-line.
You must print it out and deliver it to UNI Student Health Clinic either by mail or in person:
University of Northern Iowa
Student Health Clinic
Attention: Medical Records
Building 0221
Cedar Falls, IA 50614-0221 OR Fax to: 319/273-3155
To download this form:
Option 1: PDF Format
Click here to download the Release Medical Information Form in PDF format (If you do not have Adobe Acrobat Reader, Click here to download it from the Adobe web site.)
Option 2: JPG Format
The Release Medical Information Form is in JPG format. This will allow you to open the file in an Internet browser & can be printed using the "Print" button, found on both Internet Explorer and/or Netscape browsers. Click Here to view & print page 1 of the form.
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