Release of Information – Professional Step 1 of 3 33% Patient InformationPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Parent / Guardian (if patient is a minor) First Last Email(Required) Telephone Number(Required)Patient Address(Required) Street Address City State / Province / Region ZIP / Postal Code I hereby authorize Indiana Health Group to: Request records FROM: Release records TO: Both Verbal Communication Name of person, provider, or organization to release/retrieve records to/from(Required)Address of person, provider, or organization listed above: Street Address City State / Province / Region ZIP / Postal Code Email Telephone NumberFaxThe information to be released is:(Required) Communications Only (including written, verbal and electronic) Entire Patient Record Initial Assessment and Treatment Plan Testing Other Select AllThe purpose of the release is:(Required) AuthorizationConsent: Release of Information(Required) 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 the regulations specify otherwise. I understand that these records may contain sensitive information related to mental health treatment or counseling, alcohol and/or substance abuse, communicable diseases, and 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 occurred. This consent will remain valid for 12 months from the date I or an authorized representative signs below, unless I revoke it before that date or upon the completion of the specified event or conditions, whichever comes first. A copy of this authorization will be considered as valid as the original.Name of authorized person completing the release.(Required) First Last Relationship to patientToday's Date(Required) MM slash DD slash YYYY