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AUTHORIZATION FOR DISCLOSURE OR REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION Form #8014Rev. 05/21Page 1 of 1Instructions: To obtain access to protected health information maintained by Hendricks
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Gather all necessary personal information such as name, address, phone number, and insurance information.
02
Visit the Hendricks Regional Health website or contact their office to obtain the necessary forms.
03
Carefully fill out the forms, making sure to provide accurate and up-to-date information.
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Double-check the forms for any errors or missing information before submitting them.
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Submit the completed forms to the appropriate department at Hendricks Regional Health either in person or through the mail.

Who needs hendricks regional health?

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Anyone seeking medical treatment or services from Hendricks Regional Health.
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Individuals looking to establish care with a healthcare provider in the Hendricks Regional Health network.
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Patients in need of emergency medical care or hospitalization in the Hendricks Regional Health facilities.
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Hendricks Regional Health is a healthcare system located in Hendricks County, Indiana.
All residents of Hendricks County, Indiana are required to file Hendricks Regional Health.
To fill out Hendricks Regional Health, individuals must complete the required forms online or in person.
The purpose of Hendricks Regional Health is to provide medical care and services to the community.
Information such as personal details, medical history, insurance information, and any treatments or medications received must be reported on Hendricks Regional Health.
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