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Urgent Injury
Wait Times

All times are estimated and may not be exact.

Ankeny

Closed, Opening 7:00 a.m. Monday

Urbandale

Closed, Opening 7:30 a.m. Monday

West Des Moines

Closed, Opening 10:00 a.m. Monday

View More Locations ⟶

Obtain Medical Records

If you need DMOS to obtain your medical records from another provider, please scroll down and complete the Release of Information form below. Please note that information entered or self-disclosed on this authorization webpage requesting records will be sent over the internet to DMOS. DMOS cannot guarantee the security of self-disclosed information through the internet. Once submitted, processing takes 5-7 business days. For secure handling, patients may request secure processing by submitting a completed Medical Records Release form. Please print and complete the entire form. Once completed, mail the form to:

DMOS Orthopaedic Centers
c/o Medical Records
6001 Westown Parkway
West Des Moines, Iowa, 50266

Patients may also fax the completed request to 515.224.5337. Mailed/faxed requests take 5-7 business days from the receipt date to be processed.

DMOS – Ankeny, Des Moines, Urbandale & West Des Moines

For urgent requests, please call 515.224.1414, option #6 for Medical Records
Fax: 515.224.5337

Step 1: Patient Information

First Name

Last Name

Previous Names

Parent Name(s) for Patients Under 18:

Phone

Address

Address Line 2

City

State

Zip Code

Birth Year (Four Digits)

Step 2: Provider Information

Provider Name

Clinic Name

Address Line 1

Address Line 2

City

State

Zip Code

Provider Phone Number

Provider Fax Number

Step 3: Types of Records to Obtain

Documentation of Materials Requested

Complete Medical Records

Medical Records for the Following Dates Only:

Step 4: Medical Imaging Records Request

Options

Copies of X-Rays sent electronically to physician

Copies of MRI sent electronically to physician

Copies of CT sent electronically to physician

Step 5: Purpose of Release

This protected health information is being used or disclosed for the following purposes:

Personal

Second Opinion

Insurance

Other

Step 6: Provider Delivery Method Options

How would you like to receive your records?

Securely email my records to medicalrecords@dmos.com

Fax my records to DMOS at 515-224-5337

*Radiologic (X-ray, MRI, CT) images will be sent electronically as per your request on Step 4.

Step 7: Sign and Submit

Please read the following disclosure:

This authorization is effective for months but no longer than 1 year from the date on which it was signed. (If left blank this document is good for 1 year from the signature date. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to the Medical Records Department of the source facility. I understand that I have the right to inspect the information to be disclosed upon the proper notification to and under conditions established by the source facility. I understand that my health care and payment for my health care will not be affected if I do not sign this form. I understand this authorization is voluntary. I understand that if the recipient of this information is not a health plan or provider, the released information may no longer be protected by federal privacy regulations and may be subject to re-disclosure. I understand that I am entitled to receive a copy of this completed authorization form.

Today's Date - Authorization Notice

Prohibition of re-disclosure:

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, and HIV/AIDS tests results, federal requirements (42 CFR Part2) and state requirements (IA Code ch.228&ch.141) (740 Ill. Comp. Stat. § 110/5) (Wis. Code §§252.15(6), 50.30) prohibit further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may result from unauthorized disclosure of alcohol/drug abuse, mental health or HIV/AIDS related testing and or treatment.

Today's Date - Prohibition of Re-Disclosure

Privacy Notice

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to DMOS’s Privacy Officer. Please refer to DMOS’s Notice of Privacy Practices. I understand that a revocation is not effective to the extent that DMOS has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. DMOS will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I provide authorization for the requested use or disclosure.

Please read the Privacy Notice above and check the box below.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to DMOS’s Privacy Officer.

By checking this box, I understand that I am sending Private Health Information (PHI) over the internet to DMOS.

I understand I am sending my PHI over the internet.

Signature of Patient or Personal Representative
By typing my name, I am authorizing my signature.

Full Name