Patient parking verification form

A citation may be issued to a vehicle parked in a patient-designated area if it is registered to a University of Iowa employee. Learn more about employee parking for health care appointments

If a citation is received for this reason, complete this form to allow Parking and Transportation to verify appointments with UI Health Care and cancel the citation. In compliance with HIPAA privacy guidelines, UI Health Care can only confirm the existence of an appointment and does not access any medical information.

Please complete the required fields with a red star to enable verification and cancelation of this type of citation.

Note: If you had an appointment at the University Medical Center campus attaching a photo of your Patient Parking Pass will allow your request to be processed immediately without additional verification. You may upload a photo of the physical pass provided by your clinic or a screenshot from your UI Health Care MyChart account.

Employee First Name

Employee Last Name

University ID #

Date the citation was issued

Patient Name

Transaction number of parking citation

Patient Parking Pass (optional)

One file only.
10 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, avi, mov, mp3, ogg, wav, bz2, gz, sit, svg, tar, zip.

Validation specific to your appointment (optional)

One file only.
10 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, avi, mov, mp3, ogg, wav, bz2, gz, sit, svg, tar, zip.

Second validation specific to your appointment (optional)

One file only.
10 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, avi, mov, mp3, ogg, wav, bz2, gz, sit, svg, tar, zip.