Indiana Medical Records Release Form 1
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Authorization to Release Medical Records
Records to be released from

Interventional Pain Care, LLC
5501 W. Bethel Ave.
Muncie, IN 47304

I hereby request and authorize the above provider to furnish records for the purpose of
____________________________________________________ or at my request.
Records to be sent to:
Provide complete name,
address, and zip code

_________________________________________
_________________________________________
_________________________________________

Patient Information
Patient Name
_______________________________
Address
_______________________________
City, State, Zip _______________________________

Phone
DOB
SS#

________________
_________________
_________________

Information that may be released:
___ All records
___ Office Visit Notes
___ Prescription
___ Labs
___ History & Physical ___ Consultation report(s)
___ Therapy notes
___ Discharge Summaries ___ Image reports (MRI, x-ray, etc.)
___ Operative Reports
___ Other _______________________