Request for Release of Information

Here is a Release of Information Form that you can use to obtain records from Ellsworth Municipal Hospital for your doctor, or for your Medical Records if you are changing a physician provider clinic. Please note that the first page is for general medical information only, and the second page of this release is for specific protected information, including Mental Health, HIV/AIDS, and Chemical Dependency. It is not necessary for you to complete page two of the Release of Information Form, if the information you are releasing does not apply to those areas. (Mental Health, HIV/AIDS, and Chemical Dependency)

General Medical Information
(Page 1 only)

General Medical Information & Special Release
(Two pages, including Mental Health, HIV/AIDS, and Chemical Dependency)

Return or mail completed Release of Information form to:

Ellsworth Municipal Hospital
110 Rocksylvania Avenue
PO Box 668
Iowa Falls, IA 50126-2400

Call Medical Records at EMH (641-648-7057) if you have any questions regarding the Release of Information Form for your EMH Medical Records.

For questions on releasing your clinic records to amother provider, please contact the Medical Records staff at your clinic.