Request for Disclosure of Public Health Records

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Complete this form to request disclosure of public records with the Morgan County Department of Health. Please note: Records requests will be fulfilled as time allows, but may take up to 7 days under IC 5-14-3.

* Denotes a required field

Date:

MonthDay Year,

Name:*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Phone:*

Phone Area Code-Phone 3-Phone 4 ext Extension

Fax:

Phone Area Code-Phone 3-Phone 4 ext Extension

E-mail:*

Please identify the record(s) you wish to copy. Your description should be as specific as possible in order to expedite location of the record(s).

Please Do Not Complete The Following Field

Record(s):*

Please state the reason that want to view this record. (Optional)

Reason:

By checking this box, you agree that all information included in this disclosure is truthful to the best of your knowledge.*

I agree.

Request for Disclosure of Public Health Records

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