Release of Information Request Form

To view/download the form to transfer records from JCHC to another facility, click HERE.
To view/download the form to transfer records from another facility to JCHC, click HERE.
To view/download the form to obtain your own records: click HERE.

Please turn the completed form in to the HIM Department at Jefferson County Health Center via:

1. Fax: 641-469-4199, or
2. In person at JCHC HIM Department, M-F 7:30 am – 4:00 pm., or
3. By email: medicalrecords@jchc.org. (*Prior to emailing the form, please ensure you have signed your name. Electronic signatures will not be accepted.)

Questions? Please call the HIM Department at 641-469-4430.