§ 16-39-1-4 — Patient's written consent for release of records; contents

Except as provided in IC 16-39-5, a patient's
written consent for release of the patient's health record must include
the following:
(1) The name and address of the patient.
(2) The name of the person requested to release the patient's
record.
(3) The name of the person or provider to whom the patient's
health record is to be released.
(4) The purpose of the release.
(5) A description of the information to be released from the health
record.
(6) The signature of the patient, or the signature of the patient's
legal representative if the patient is incompetent.
(7) The date on which the consent is signed.
(8) 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.
(9) The date, event, or condition on which the consent will expire
if not previously revoked.
[Pre-1993 Recodification Citation: 16-4-8-4.1.]

Legislative History

As added by P.L.2-1993, SEC.22.