SICHC - Authorization to Release of Mental Health/Behavioral Information

Patient Name

First

Last

Date of Birth

Month/Day/Year 00/00/0000

Social Security Number (SSN)

000-00-000

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

I hereby authorize release of information:

To release healthcare information of the patient named above to the SICHC Location (choose below):

Previous Provider / Doctors Office

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

FAX

Record Preferences:

Last Two Year(s) Office Visits, Labs and Diagnostic Tests

Other:

To authorize the release of mental/behavioral health records, in addition to medical records, a separate Authorization for Release of Medical Records must be completed.

Security FAX RECORDS

Reason for Disclosure:

Continuation of Care/Transfer of Care

Other:

Signatures

I understand that I may revoke this release at any time in writing. This request shall remain valid until revoked or upon the expiration of sixty (60) days, whichever comes first. I also understand that this release alcohol and/ or substance abuse information. I also understand that HIV, AIDS, and/or any STD might also be released. My digital signature below indicates my understanding that once my medical records have been transferred to another office, I will no longer be considered a patient of SICHC. If later, I choose to return I will be scheduled according to the “New Patient” scheduling criteria.

Patient Signature (Full Name serves as signature)

First

Last

First Name, Middle Initial or Full Middle Name, and Last Name

Date

Parent/Guardian Signature (Full Name serves as signature)

First

Last

First Name, Middle Initial or Full Middle Name, and Last Name

Date

RELEASE OF MEDICAL RECORDS SUBMISSION INFORMATION*

Southern Indiana Community Health Care - Paoli
PO Box 270, Paoli, IN 47454
Phone (812) 723-3944
Fax (812) 723-7989 or (812) 723-7128

Southern Indiana Community Health Care - Marengo
Crawford Family Health 5604 E. White Oak LN, Marengo, IN 47140
Phone (812) 365-3221
Fax (812) 365-2358

Southern Indiana Community Health Care - English
307 S. Indiana Ave., English, IN 47118
Phone (812) 338-2924
Fax (812) 338-3706

Southern Indiana Community Health Care - West Baden
8163 W. ST RD 56, Suite A, W. Baden, IN 47469
Phone (812) 723-7125
Fax (812) 936-2599

Southern Indiana Community Health Care - Mitchell
2759 State Road IN-37, Mitchell IN, 47446
Phone (812) 992-5440
Fax (812) 992-5441

Southern Indiana Community Health Care - Bedford
629 Lincoln Avenue (Lincoln Plaza), Bedford IN, 47421
Phone (812) 675-4470
Fax (812) 675-4469

SICHC – Authorization to Release of Mental Health/Behavioral Information

Signatures

RELEASE OF MEDICAL RECORDS SUBMISSION INFORMATION*

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