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Required Contents of a Patient’s Written Consent for Release of Records – Ind. Code Ann.§ 16-39-1-4

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When a patient’s written consent for release of the patient’s health record is required, the release must include the following:

  • The name and address of the patient
  • The name of the person requested to release the patient’s record
  • The name of the person or provider to whom the patient’s health record is to be released
  • The purpose of the release
  • A description of the information to be released from the health record
  • The signature of the patient, or the signature of the patient’s legal representative if the patient is incompetent
  • The date on which the consent is signed
  • A statement that the consent is subject to revocation at any time, except to the extent that action has been taken in reliance on the consent
  • The date, event, or condition on which the consent will expire if not previously revoked

Related Laws:

Ind. Code § 16-39-5-1

Ind. Code § 16-39-5-2

Current as of June 2015