Authorization for the Release of Information Form - IU Health - iuhealth 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name, date of birth, and medical record number in the designated fields at the top of the form.
3. Fill in the patient’s address and any previous names, along with their social security number.
4. Indicate whether you authorize Indiana University Health to release, receive, or verbally communicate information by checking the appropriate boxes.
5. Provide the name and address of the person or agency that will receive or send information.
6. Select which specific health information you wish to access by checking the relevant boxes, including options like operative reports and lab reports.
7. Specify the dates of service needed for your records.
8. State the purpose for this release, such as further treatment or legal reasons.
9. Sign and date the form at the bottom, ensuring all required signatures are included if applicable.

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