Request for Release of Clinic Information

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This form is to request the release of information from the Morgan County, Indiana Health Clinic.

* Denotes a required field

I give permission to the Morgan County Health Department to request/release information of a medical, dental, psychological, and/or social nature concerning:

Patient Name (First, Middle, Last):*

To (Person Requesting the Information):*

Name of Person Requesting Information:*

...who can provide health consultation, study, treatment or access to programs which will further my (the patient's) health status. (Any limits on information to be shared are specified below.) This authorization shall be continue until receipt of a written notice of withdrawal.

E-mail:*

Please Do Not Complete The Following Field

Address*

Address 2

City*

State*

ZIP*

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

When you have submitted this form, you will be provided with an email to send a copy of your Picture ID and, if applicable, Guardianship Papers.

By checking the button below, I hereby certify that I am the requestor named above and that I am authorized to request a certified copy of the record for the above named individual, in accordance with Indiana Code and Indiana Administrative Code. I understand that penalties are described by law for misrepresentation on this request.

I agree to the above statement:*

Yes

Request for Release of Clinic Information

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