Ind. Code § 16-39-1-4

Patient's written consent for release of records; contents

Applied in 1 court decision — leading case E.J., a minor by his mother and father Victor and Lynell Jeffrey v. Paul Okolocha, M.D., Okolocha Medical Corp., and Okolocha Medical, Pain and Weight (2012)

Most recently applied in E.J., a minor by his mother and father Victor and Lynell Jeffrey v. Paul Okolocha, M.D., Okolocha Medical Corp., and Okolocha Medical, Pain and Weight (August 2012)

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

Sec. 4. 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.

Official source: Indiana General Assembly. Reproduced from public-domain Indiana statutes; confirm against the official source for the current text. Not legal advice.