180 S. Main St., Ste. 252, Martinsville, IN 46151

765-342-6621, Fax: 765-342-1062 morgancohd@morgancountyhealth.com

Request for Release of Information Form

Request for Release of Clinic Information

*Release of Information Form*

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:*
Address of Requestor:*
Upload a Copy of Picture ID (jpg, jpeg, png, gif, doc, docx, xls, xlsx):*
Upload Guardianship Papers, if required (jpg, jpeg, png, gif, doc, docx, xls, xlsx):

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.*
Word Verification: