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Scroll down and check for available dates before entering patient info. If no appointments are available, check back later. If you have remaining questions, please call us at (515) 957-0001. Page 1 of 3 HIPAA Release Form Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested. To verify the form is now compliant go to where the form is rendered on the page and you should now see an additional section at the bottom of the form right above the submit button showing a checkbox to agree to the HIPAA privacy agreement, a badge showing the form is encrypted and HIPAA compliant and the signature field which a user can sign Ensure that your sensitive healthcare information is protected. JotForm provides HIPAA compliant forms and a business associate agreement (BAA) so your organization can collect health information that is safe and secure. Start collecting HIPAA-Secure data in 3 easy steps!

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