Medical Information Release Authorization Form

Medical Information Release Authorization Form
I hereby authorize the release of health records of Patient Name* kept by Statewide Transfer Ambulance & Rescue, Inc. (dba STAR Ambulance).
Name of Requestor *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Service (ie ambulance transport)*

MonthDayYear
Date
Reason for Information Request:*
Mailing Address or Email Address that records should be remitted to:*
I understand that pursuant to Indiana law, I may revoke this authorization at any time in the future.

I declare subject to the criminal penalty of false swearing established in IC 35 44.1-2-1 that the foregoing statements are true and correct, and that I have not applied and been denied access to the requested records by any court.
Signature of Patient or Authorized Representative*

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