Medical Record Request
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1MEDICAL RECORD REQUEST
Please fill out the form completely. Fax or Mail Release to:
Medical Records Release
550 Landmark Ave
Bloomington, IN 47403
Phone: 812-355-6961
Fax: 812-355-3269
Patient Name:
(Please print)
__________________________________________________________
Patient Phone # : ______________________________
Last name
First Name
Middle Initial
Social Security #:
Date of Birth:
___________
_______
_______________
Month ________
Day _____
Year ____________
Patient Address:
__________________________________________________ City ____________________ State _____________ Zip __________
I authorize Premier Healthcare, LLC
I authorize Premier Healthcare, LLC
to RELEASE my records to:
to RECEIVE records from:
Name:
Name:
Full Address:
Full Address:
Fax #:
Fax #:
Phone #:
Phone #:
Charges for copies of documents shall be in accordance with Indiana Code 16-39-9-3 and 760 IAC 1-71-3
Purpose of Release:
Specific records from the following dates: __________________________
Continuing medical care (No charge will be made if sent directly to
another physician). One to two years of current records will be sent.
Health Record(s) (to include mental health, drug or alcohol use/abuse,
communicable diseases, pregnancy and HIV/AIDS).
Personal use:
A fee of $20.00 applies which includes the first ten (10) pages.
• Fifty cents ($0.50) per page for pages eleven (11) through fifty (50).
• Twenty five cents ($0.25) per page for pages fifty-one (51) and higher.
• The actual cost of mailing the copy.
• An additional $10.00 fee will be applied if records are needed within
two (2) working days.
I, the undersigned, understand that I may REVOKE this authorization at any time, in writing, but the request shall remain valid until
revoked or upon the expiration of 90 days, whichever occurs first, EXCEPT to the extent that action has been taken. Information
used or disclosed may be subject to re-disclosure and no longer protected by the HIPAA rule. I understand that my medical
information may include treatment for physical and/or emotional illness, communicable disease, alcohol or drug abuse treatment,
pregnancy, HIV, AIDS, or AIDS-related information, unless I otherwise restrict such release of information.
Authorization must be signed by the parent or legal guardian of any patient under 18 years of age. Emancipated minors may sign for
themselves. The personal representative/executor of estate may sign for a deceased patient’s information. If no personal
representative/executor, then the spouse, child or sibling may sign.
________________________________________________________________________________________________________________________
Patient Signature
Date Signed
_____________________________________________________________
________________________________________
Patient/Guardian
Date Signed
_____________________________________________________________
________________________________________
Record Released by
Date Signed
_____________________________________________________________
________________________________________
Revised 10/10/2011
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