I hereby request and authorize:
Indy Behavioral Health
2611 Waterfront Parkway East Drive, Suite 370
Indianapolis, IN 46214
Phone: 317.978.0257 Fax: 317.974.9077
a copy of my mental health information to/from the person or agency listed below:
This consent is subject to revocation at any time except to the extent that the individual/agency which is to make the disclosure has already taken action in reliance on it. If not previously revoked, this consent will terminate in 12 months or upon termination of treatment.
Indicate your relationship to the client and/or reason and legal authority for signing:
** This information has been disclosed from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.