Release of Medical Information

We understand the importance of maintaining our patients' privacy and protecting their medical information. The Health Information Portability and Accountability Act (HIPAA) became effective on April 14, 2003. The regulations specifically outline various protocols regarding the handling of a patient's medical information and detail the requirement for all healthcare providers (transmitting insurance claims electronically) to notify patients of how their medical information could be used and/or disclosed. To comply with these regulations we have developed our Notice of Privacy Practices. If you have any questions regarding this Notice or our privacy practices in general, please feel free to call our Privacy Officer at (317) 471-4304.

To download and print a copy of Indiana Hand to Shoulder Center's medical information release form please click on the appropriate version below. You will need Adobe Acrobat Reader to view the forms. If you do not have Adobe Acrobat Reader, please download the free program.

Download release of Information Form (118 KB PDF)

Download Notice of Privacy Practices (160 KB PDF)

Obtaining Your Medical Information

Should you need to obtain copies of your medical information, we must receive payment before any information will be released. Please send $20.00 (checks made payable to Indiana Hand to Shoulder Center) along with the completed Authorization to Release Medical Information Form to 8501 Harcourt Road, Indianapolis, IN 46260, Attn to: Release of Information. Any additional charges will be billed to you at a later date.

The cost for copying your medical records will be calculated as follows:

1st Ten (10) pages = $20.00 – standard fee
pages 11 – 50 = .50 each page
pages 50+ = .25 each page

X-rays = $10.00 each

Large X-rays are given on a LOAN BASIS only.

Please allow 10-14 days for processing. Any questions regarding the release of your medical records should be directed to (317) 471-4476 or fax: (317) 872-1328.