Medical Records Release of Information

Release of Information

Damien Center
What type of release is this?*
Personal UseContinuing Care (in addition to the care you are receiving)Transfer of Care (no longer receiving care)Litigation/LegalInsuranceOther

Patient Information
Client's Legal Name:*

First NameLast Name
Have you ever used a different legal name?

First NameLast Name
Client's Birth Date:*

MonthDayYear
Client's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.

Releasing Protected Health Information
Releasing Facility:

Damien Center
1420 East Washington Street
Indianapolis, Indiana 46201
Phone: 317.423.0130
Fax: 317.423.0608
Who has the information to be released?*
What is their address? *

Street Address

Street Address Line 2

CityState

Zip Code
Where would you like your medical records sent?*
What is their address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is their phone number?*
Please enter a valid phone number.Format: (000) 000-0000.
Should your records be sent to someone's attention? If so, please list them below.

Obtaining Protected Health Information
Who has your medical records?*
Please enter the name of the facility and provider, if known.
What is their Address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is their Phone Number?*
Please enter a valid phone number.Format: (000) 000-0000.
What is their Fax Number?
Please enter a valid fax number.Format: (000) 000-0000.
Receiving Facility:

Damien Center

1420 East Washington Street

Indianapolis, Indiana 46201

Phone: 317.423.0130

Fax: 317.423.0608
Receiving Facility:*
Receiving Facility's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Releasing Instructions
Paper (Paper requests take an average of 2-4 weeks to complete.)USB (Digital Media)Secure EmailSecure FaxVerbal communication only
What is the secure Email Address?*
example@example.com
What is the secure Fax Number?*
Please enter a valid phone number.Format: (000) 000-0000.

Signature Page
Expiration Date: This authorization expires 60 days after the date signed. To extend beyond 60 days, enter the later expiration date here (up to 180 days). If left blank, the authorization will expire after 60 days.

MonthDayYear
Date
- I understand that I have the right to revoke this authorization at any time. To revoke this authorization, I must do so in writing and present my written revocation to the above-named authorized entity. This revocation will not apply to information that has already been released in response to this authorization.
- I understand that I will not be denied treatment if I do not sign this authorization.
- I understand that I may see and copy the information described on this form if I ask for it, and that I get a copy of this form after I sign it.
- I understand that Damien Center, Inc. cannot prevent redisclosure of my information by the person or organization who receives my records pursuant to this authorization, and that information may not be covered by state and federal privacy protections after it is released. I understand that by signing this authorization, I release Damien Center, Inc. from any liability resulting from a redisclosure by the recipient.
I would like my requested information to be Certified. I understand that this may warrant additional fees.
Expiration Date: This authorization will expire in 60 days from the date signed unless otherwise specified. (Not to exceed 180 days) {expirationDate}
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Release of Information

Patient Information

Information to be Released

Releasing Protected Health Information

Obtaining Protected Health Information

Releasing Instructions

Signature Page