Release of Medical Info Form - Indiana - American Health 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s information, including their first name, last name, date of birth, and last four digits of their Social Security number. Ensure accuracy for proper identification.
3. Fill in the address details for both the patient and the recipient of the medical records. This includes street name, city, state, and zip code.
4. Specify the records to be released by selecting from options such as AHN provider notes or lab reports. You can also indicate specific dates for service records.
5. Indicate the reason for disclosure by checking appropriate boxes like 'Continuing Care' or 'Personal'.
6. Review all entered information for accuracy before signing. The authorization will expire in 60 days unless specified otherwise.

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