Directory information, not recipient confirmation. Fax numbers can change and differ by department, location, form, or plan. Confirm this destination directly with Michiana Behavioral Health before sending sensitive documents. FaxFlow is not affiliated with this organization.
Michiana Behavioral Health fax number
(574) 941-5703
Behavioral Health
Used for: PHI release form submission / medical records request
Fax destination details
- Department
- Behavioral Health
- Purpose
- PHI release form submission / medical records request
- Form
- Authorization for Release of Protected Health Information — Authorization for Release of Protected Health Information
- Address
- 1800 N Oak Dr, Plymouth, IN 46563
- Voice phone
- 574-936-3784
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Complete patient name, birth date, any previous names, dates of service; indicate whether records are released to Self or an Agency/Organization and provide recipient's name, telephone, and mailing address; sign and date; submit according to the form's directions.
Official form instructions are published as a downloadable file on the organization's website.
Sources and verification
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