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

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