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2002 S East Street Indianapolis, IN 46225 T.317.803.9715 F.317.454.8573
Authorization to Disclose Health Information
I (the undersigned) hereby authorize GRM to disclose the following identified health information.
Patient Information
*First Name:
*Last Name:
Maiden Name (if applicable):
*Date Of Birth:
*Address:
*City:
*State:
*ZIP Code:
*Phone Number:
*Email:
*SSN (Last four):
Release Information From
*Provider State:
*Provider Name:
Information to be Released
Dates of Treatment Requested:
*From:
*To:
Information to Release:
All Records
Abstract (includes 2 years of office visits, labs, immunizations, diagnostics & radiology reports)
Treatments received
Optometry Records
Dental Records
Labs
Operative Reports
Consultation Report(s)
Therapy Notes
Prescriptions
Discharge Summary(s)
Office Visit Notes
History & Physical
Test & X-Ray Reports
Other
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.
Limitations:
Do not release information in my records regarding:
Sensitive Information

Fenway Health WILL NOT disclose the following information without your signed authorization. Please select box next to each type of record you will like to be released.

I Allow disclosing sensitive information


Limitations

ONLY release information in my records regarding:

Abortion Care
Alcohol/Substance Use Treatment
Behavioral Health (Medical Provider)
Behavioral Health (psychiatrist, therapist, mental health clinician or social worker)
Genetic Testing
HIV/Aids Results or related care
Intimate Partner Violence Counseling
Sexually Transmitted Diseases
Sexual Violence Counseling
Release Information to
Release Information to Patient
Company Name:
*First Name:
*Last Name:
*Address:
*City:
*State:
*ZIP Code:
*Phone Number:
FAX:
Email:
*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.
Patient Signature:
ID Confirmation:
Please upload a photo of yourself holding a driver's license or other forms of secondary authorization.
Relationship to patient, if other than patient:




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