This request is good for 60 days from the date signed pursuant to I.C. 16-39-1-1 unless indicated otherwise. This request may be revoked by the patient at any time by communicating that intent in writing to the provider.
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By filling out this form, you are agreeing to the following:
Please note: There may be a charge assessed by your previous physician’s office for copying the medical record. Please contact them for more information.
Name of doctor at Northpoint Pediatrics
Date of Birth
Patient's zip code
Patient's phone number
Name of Practice or Organization releasing information to Northpoint Pediatrics
Practice or Organization’s phone number
Information to be disclosed:
If you choose other, you must indicate what information to share:
Practice or Organization’s address
Practice or Organization’s city
Practice or Organization’s state
Practice or Organization’s zip code
How should records be sent to Northpoint Pediatrics?
Name of person filling out the form
Sign your name:
Please use your mouse, stylus, or finger to sign your name in this box.
I authorize the release of information protected by Federal and State Regulations including alcohol/substance abuse, mental health documentation, and HIV results.
9669 E. 146th Street
Noblesville, IN 46060
8101 Clearvista Parkway
Indianapolis, IN 46256
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