Release of Information – Personal Patient InformationPatient Name(Required) First Last Date of Birth(Required) Phone(Required)Email(Required) Person Completing This ReleaseIs the person completing this release the same as the patient?(Required) Yes No Does the person completing this form have legal authority to complete this release of information on behalf of the patient?(Required) Yes No Unable to ProceedWe cannot release your information because the person who signed this form is not authorized to do so. Only authorized individuals can give permission to share your information. Please contact our office at 317-843-9922.Disclosure Authorization: Information & RecipientSpecified information to be released(Required) Appointment Scheduling Billing / Insurance Treatment Select AllI hereby permit Indiana Health Group to release and/or communicate the specified information to the parties listed below.Name(Required) First Last Relationship(Required)Phone(Required)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.This field is hidden when viewing the formSignaturePrinted Name of Patient(Required) First Last Printed Name Authorized Signatory(Required) First Last Email of person completing the release.(Required) Telephone number of person completing the release.(Required)Today's Date(Required)
