To schedule an appointment or for any questions, you may reach our office at 812-372-6274

Health Information Disclosure Form

For your convenience we are providing a downloadable PDF Form for the purpose of Health Information Disclosure.

Just click on the link, fill out the information and click the Submit Button. You can also save the PDF Form to your computer for records.


360 Plaza Drive, Suite B
Columbus, IN 47201


Phone: (812) 372-6274

Columbus Office Hours:
Monday, 8:30 – 5:00
Tuesday-Friday, 8:30 – 4:30