With any questions, please contact Medical Records at 712-542-8302.

Clarinda Regional Health Center Information:

220 Essie Davison Drive, Clarinda, Iowa 51632

Phone Number: 712-542-8302

Fax Number: 712-542-8346

Request for Authorization For Disclosure of Health Information

  • PATIENT INFORMATION

  • RELEASE INFORMATION FROM

  • RELEASE INFORMATION TO

  • RELEASE INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • The following person(s) has permission to pick up my medical record

  • Date Format: MM slash DD slash YYYY
    (insert date here if applicable)
  • (type name for signature)
  • (if you are filling this out for yourself, type "Self")
  • Date Format: MM slash DD slash YYYY

If you would prefer to mail it in, here is a copy you can download and mail in.

Please mail to CRHC Attn: Medical Records, 220 Essie Davison Drive, Clarinda, Iowa 51632