Medical Records

Medical records are maintained by Health Information Management (HIM). HIM is available from 7:30 am - 4 pm, Monday – Friday, excluding holidays. The HIM Department is located on the main level of the hospital near the Business Office.

To obtain a copy of your medical records:

  • Download and complete the Authorization to Release Health Information FROM Pella Regional (PDF), clearly stating the dates of service, the specific type of record(s) desired and all other information indicated on the form. 
  • Download and complete the Authorization to Release Health Information TO Pella Regional (PDF), clearly stating the dates of service, the specific type of record(s) desired and all other information indicated on the form. 
  • All section (1 - 13) must be completed. Incomplete authorization forms cannot be processed and will be returned for completion. 
  • This form may also be obtained in HIM or you may request the form to be mailed or faxed to you. 
  • Mail, fax or drop off your completed form to HIM (address/fax number below). 
  • Because forms must contain original signature, e-mailed forms will not be accepted. 
  • Please allow up to 30 days for requests to be processed. Most requests are processed within 14 business days. 
  • If you wish to have your records mailed to your physician prior to an appointment date, please indicate the appointment date on the request. 
  • If you are picking up a copy of your record, a photo ID will be required. Please note that only the patient/requestor may pick up a copy of the record unless stated in the authorization. 
  • The authorization must be signed by the patient or the patient’s legal representative. Legal guardian or person with durable power of attorney documentation required. 

HIM reserves the right to contact the patient/requestor to validate the authorization before releasing the records. 

Authorization to Share Information

Maintaining your privacy is very important to our staff. If you would like us to share your information with a spouse, family member or caregiver we require written consent. Download consent form. (PDF)

Permission for Treatment of a Minor

We understand that there are occasions when you cannot accompany your minor child to their appointment. At those times, we require written consent. Download consent form. (PDF)

Need a copy of your Medical Records or Radiology Images?

Fees

There is no cost to send copies of your medical records directly to another health care provider. If copies are for a patient’s personal use, the photocopying fee is $0.15 per page.

Radiology Images

Radiology Images must be obtained directly through the Medical Imaging Department by calling 641-628-6620.