Request for Release of Medical Records

Your Name*

First NameLast Name

Phone number we may reach you at*

Area CodePhone Number

Pet(s) Name*

Where would you like your records sent? *

Name of Animal Hospital/Clinic/Shelter

Phone number of hospital/clinic/shelter receiving records

Area CodePhone Number

Fax or e-mail address where records should be sent

I understand that I have the right to revoke this authorization at any time. My revocation must be in writing and provided to Morris Animal Hospital. I understand that the clinic, veterinarian, or representative will have disclosed privileged information on my behalf and authorize them to do so.

In accordance with Indiana code IC 25-38.1-4-5.5, I understand that my pet's veterinary medical records and medical condition must be furnished within five (5) business days without my written authorization under the following circumstances:
(1) Access to the records is specifically required by a state or federal statute.
(2) An order by a court with jurisdiction in a civil or criminal action upon the court's issuance of a subpoena and notice to the client or the client's legal representative.
(3) As part of an inspection or investigation conducted by the board or an agent of the board.
(4) As part of a request from a regulatory or health authority, physician, or veterinarian:
(A) to verify a rabies vaccination of an animal; or
(B) to investigate a threat to human or animal health, or for the protection of animal or public health and welfare.
(5) As a part of an animal cruelty report and associated applicable records that are part of an abuse investigation by law enforcement or a governmental agency.
(6) To a law enforcement agency as part of a criminal investigation.

I hereby allow the release of my pet's medical records from Morris Animal Hospital.

Signature*

Date

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