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I give the Department of Human Services permission to share with confidential information about me or my household. The information that can be shared is:.5880 UNIVERSITY AVE, STE 209 • WEST DES MOINES, IA 50266 • PHONE: 515-633-3880 • FAX: 515-246-4485. MercyOne Iowa Heart Center Medical Records Department (address at top of this form) or completing the Revocation for Authorization form. All the below sections must be completed and the student must sign and date this form. Pursuant to the Family Educational Rights and Privacy Act (FERPA), the Confidential Records Section of the Iowa Open Records Act, Iowa Code, Section 22. Please mail the full completed authorization(s) to the appropriate UnityPoint Health facility listed in the above Release of Information section. I understand that I am entitled to receive a copy of this completed authorization form. INFORMATION: D Complete Records. Use our HIPAA-compliant form to authorize the release of medical information.