Authorization + Release Forms

Following is a list of the most frequently requested forms that may be required as you pursue treatment for yourself or a family member. They are supplied in PDF format for the ease of printing and in turn filling out as requested.

• Authorization for Release of Protecected Health Information- English
• Authorization for Release of Protected Health Information- Spanish
• Consent for Disclosure of Health Information
• Consent for Disclosure of Health Information - Spanish
• Consent for Vaccination with Athletic Physical
• Iowa Athletic Pre-Participation Physical Examination

Myrtue Regulations for Service Animals

For additional questions, contact:

• Myrtue Administration: 712.755.4316
• Infection Prevention: 712.755.4247
• Risk Management: 712.755.4358

You can find more information at:

U.S. Department of Justice Civil Rights Division
950 Pennsylvania Avenue, NW | Washington, D.C. 20530-0001
Website: ada.gov | Phone: 800.514.0301

What animals are allowed at Myrtue locations?

Service animals are the only animals allowed within the institution per their owner’s needs. They may enter all areas of a hospital generally accessible to the public, such as

• Lobbies
• Cafeteria
• Patient care areas on unrestricted units

Accommodations for other areas of the facility will be determined on a case-by-case basis.

What is a service animal?

Dogs or horses that are individually trained to do work or perform tasks for people with disabilities. Examples of service animal tasks include:

• Guiding persons with visual impairments
• Pulling a wheelchair
• Retrieving dropped items
• Alerting individuals with hearing impairments to the presence of intruders or sounds
• Lick the hand of a person with PTSD to alert them to an oncoming panic attack
• Detect the onset of a seizure and then help the person remain safe during the seizure

Exotic animals are not permitted.

Other types of animals:

Therapy Animals:

• Therapy animals will only be permitted in inpatient units and with prior authorization
• Animals utilized in this program will be registered through a nationally recognized therapy program and at least one year of age.

Emotional Support Animals:

• Emotional support animals will only be permitted in inpatient units and with prior authorization
• Allowance of emotional support animals in other areas may be addressed on a case-by-case basis with prior notification from the owner
• Emotional support animals are only to visit the patient/owner, and the visit must take place in the patient’s private room
• Visiting other areas in the facility is not permitted
• The handler will transport the animal directly to and from the patient’s room/area when patient is available to see the animal

Personal Pets:

• Personal pets are only to visit the patient/owner with prior authorization, and the visit must take place in the patient’s private room
• Visiting other areas in the facility is not permitted
• The handler will transport the animal directly to and from the patient’s room/area when patient is available to see the animal
• The visit will be limited to two hours
• Personal pets are not allowed in the clinic setting

Additional Information:

Removal of a service animal from the premises will only occur if:

• The dog is out of control and the handler does not take effective action to control it
• The dog is not housebroken
• When there is a legitimate reason to ask that a service animal be removed, staff must offer the person with the disability the opportunity to obtain goods or services without the animal’s presence

An animal must be under the control of its handler. Under the Americans with Disabilities Act (ADA), service animals must be harnessed, leashed, or tethered, unless the individual’s disability prevents using these devices or these devices interfere with the service animal’s safe, effective performance of tasks. In that case, the individual must maintain control of the animal through voice, signal, or other effective controls.

The animal’s presence will not jeopardize the safe operation of the facility or health of the patient.

The animal will not pose as a direct threat, defined as a significant risk to the health or safety of others that cannot be mitigated or eliminated by modifying policies, practices, or procedures.

This must be based on actual behavior of the particular animal and not on speculation about how the animal may behave.

Owners are liable for the animal’s behavior/actions, and any damage or injury caused while the animal is on Myrtue Medical Center property.

Visiting Animals:

Will...

• Appear healthy
• Be recently bathed/groomed
• Be free of parasites, open wounds, ear/skin infections, hot spots or urinary/fecal incontinence
• Be well behaved
• Be up to date on all required vaccinations

The owner/handler may be asked to provide proof of up to date animal vaccination.

Responsibility for care of the animal (care, feeding, cleaning, exercise, and elimination needs) during the stay must be assigned to an adult who is not the patient and is not a staff member or hospital volunteer.

Visits will be pre-approved and pre-scheduled with the responsible department and will be kept to an appropriate duration to allow the patient time for rest and to continue their recovery process and treatments (i.e., primary care nurse, rehab coordinator).