63 Main Street, MA 023012002 S East Street Indianapolis, IN 46225T.317.803.9715F.317.454.8573
Authorization to Disclose Health Information
I (the undersigned) hereby authorize GRM to disclose the following identified health information.
Maiden Name (if applicable):
*Date Of Birth:
*SSN (Last four):
Release Information From
Information to be Released
Dates of Treatment Requested:
Information to Release:
Office Visit Notes
History & Physical
Test & X-Ray Reports
Radiology images on CD
Itemized Billing Statement
Operative / Injection Reports
Mental Health and Psychotherapy Notes
I understand that the Protected Health Information in my medical record may include information relating to Dangerous Communicable Diseases including acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
* In addition, the following health information may be released or obtained from my health record:
- Information that may relate to treatment and/or history of psychiatric or mental health problems
- Information related to dangerous communicable diseases, includes AIDS, HIV and other infections
- Information regarding treatment for chemical dependency
Do not release information in my records regarding:
Release Information to
Release Information to Patient
*Purpose for Disclosure:
I understand that I have the right to revoke this authorization, in writing, or at any time by sending such a written notification to GRM, attention: ROI Department, 2002 S. East Street, Suite 1, Indianapolis, IN 46225. I understand that this authorization will expire in sixty, (60) days unless otherwise specified.
Expiration Date: (If not sixty days)
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand I am responsible for all fees associated with releasing my health information. I understand that I have the right to refuse to sign this authorization. By signing this authorization, I acknowledge that I have read and understand this authorization. Further, I authorize the use or disclosure of my Protected Health Information in accordance with the terms of this authorization.
Please upload a photo of yourself holding a driver's license or other forms of secondary authorization.