• Release of Information Form & Letter/Forms Request

    AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    • I authorize the use or disclosure of the above named individual’s health information as described below.
    • The following individuals or organizations are authorized to exchange information:

  • (I) The Growth Center

    4925 Charlestown Rd.

    New Albany, IN 47150

    Phone: 812-941-9200

    Fax: 812-941-9205

  • (II) Additional Release Info To/From:

  •  -
  •  -

  • 1. PURPOSE for health info disclosure (check those that apply):

  • *

  • Initials*

  • 2. SPECIFIC INFORMATION requested to be disclosed (check those that apply):

  • *

  • Initials*

  • 3. HOW would you like the information disclosed (check those that apply then initial below):

  • *

  • Initials*
  • This authorization will expire on ____/____/____ (if left blank, this document will expire one year from the date it was signed)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Signature of patient or legal guardian (patient must sign when drug or alcohol abuse is involved even if under 18):

  • Date/Time

  • Letter & Forms Request

  • Today's Date
  • Date Needed
  •  -
  • Reason for Letter

  • Processing Information
  •  -

  • *PLEASE NOTE THAT A RELEASE OF INFORMATION IS REQUIRED BY LAW FOR THE RELEASE OF YOUR HEALTH INFORMATION TO ANY THIRD PARTY (unless that entity is a legal guardian)***

  • Should be Empty: