Release of Information – Personal Step 1 of 3 33% Patient InformationPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY This field is hidden when viewing the formEmail Indiana Health Group has my permission to release/discuss the following information with the parties listed below:(Required) Appointment Scheduling Billing / Insurance Treatment Select AllName First Last RelationshipPhoneName First Last RelationshipPhoneName First Last RelationshipPhoneName First Last RelationshipPhone AuthorizationConsent: Release of Information(Required) I understand that this authorization will remain valid for the duration of my treatment. I acknowledge that, under IC 16-39 and the Federal Confidentiality Regulation 42 CFR Part 2, my health records cannot be disclosed or re-released without my written consent, unless specified otherwise by the regulations. I understand that these records may contain sensitive information related to mental health treatment, counseling, alcohol and/or substance abuse, communicable diseases, and the human immunodeficiency virus (HIV). I also recognize that I can revoke this consent at any time, except to the extent that a release has already taken place. A copy of this authorization will be treated as valid as the original. Indiana Health Group reserves the right to charge for the reproduction of medical records in accordance with state law code 760 IAC 1-71-3.Name of authorized person completing the release.(Required) First Last Relationship to patientToday's Date(Required) MM slash DD slash YYYY
