Indiana Authorization To Release Medical Information Form printable pdf download

IMPORTANT – PLEASE READ

$20.00 Copy fee (includes pages 1-10)

10-50 pages ($.50 per page)

51 pages and over ($.25 per page)

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

RECORDS TO BE RELEASED FROM:

Rehabilitation Associates of Indiana

6330 E 75

Street, Ste 110

Indianapolis, IN 46250

I hereby request and authorize the above care provider to furnish records for the purpose of ___________________

______________________________________________________________________, or at my request to

RECORDS TO BE SENT TO: ___________________________________________________

___________________________________________________

(Provide complete name, address, suite, zip code, fax # if applicable)

PATIENT INFORMATION:

_____________________________________________________________

Address: ______________________________________________________

______________________________________________________

Phone: _______________DOB_______________SS#_________________

INFORMATION THAT MAY BE RELEASED

___All Records

___Office Visit Notes

___Prescription

___History and Physical

___Labs

___Consultation Reports

___Discharge Summary

___Test & X-Ray(s)

___Other ____________

___Operative Report(s)

___Therapy Notes

____________________

I understand that this also pertains to records regarding Drug and Alcohol Treatment, Mental Health

Records, and Communicable Disease Records, including HIV and AIDS.

Limitation: Do not release information in my record regarding: ___________________________________

Release only my records for the dates of __________________through_______________________

I understand that (1) I MAY REVOKE THIS AUTHORIZATION AT ANY TIME IN WRITING, EXCEPT TO

THE EXTENT THAT ACTION HAS BEEN TAKEN BASED UPON IT: (2) THAT THE RECIPIENT OF THESE

RECORDS MAY FURTHER DISCLOSE INFORMATION BECAUSE OF THIS AUTHORIZATION AND IT

MAY THEN NO LONGER BE PROTECTED BY FEDERAL PRIVACY REGULATIONS: (3) I AM ENTITLED

TO ASK FOR A COPY OF THIS DOCUMENT: (4) I MAY REFUSE TO SIGN THIS AUTHORIZATION AND

MY REFUSAL TO SIGN WILL NOT AFFECT MY ABILITY TO OBTAIN TREATMENT. THERE MAY BE A

CHARGE FOR THE RELEASE OF THESE RECORDS PURSUANT TO INDIANA CODE 16-39-9-3 AND CFR

164.524 (HIPAA)

Signature of Patient or Patient’s Representative: ______________________________________________________

Description of Representatives Authority to Act for Patient: _____________________________________________

Date Signed: ______________________Expiration Date: 6 months or earlier date of _________________________

Authorizations for Health Records as defined by Indiana Statute may not be effective for longer than 60 days.

Released by: _________________________________________Date: ____________________________________

i:\rai original forms\rai to release information.docx

Indiana Authorization To Release Medical Information Form

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