# Ind. Code § 16-39-1-4: Patient's written consent for release of records; contents

> Indiana · Statutes · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-4

## Section

- **Citation:** Ind. Code § 16-39-1-4
- **Heading:** Patient's written consent for release of records; contents
- **Jurisdiction:** Indiana
- **Kind:** Statutes
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Indiana Code / Title 16 / Article 39 / Chapter 1 / Section 16-39-1-4

## Text

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.

[Pre-1993 Recodification Citation: 16-4-8-4.1.]

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

## Nearby sections

- [Ind. Code § 16-39-1-1 Right of access; written requests; deadline for complying with written requests](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-1.md)
- [Ind. Code § 16-39-1-2 X-rays](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-2.md)
- [Ind. Code § 16-39-1-3 Request for patient's health records; who may request](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-3.md)
- [Ind. Code § 16-39-1-4 Patient's written consent for release of records; contents](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-4.md)
- [Ind. Code § 16-39-1-5 Withholding requested information](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-5.md)
- [Ind. Code § 16-39-1-6 Inpatient requests](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-6.md)
- [Ind. Code § 16-39-1-7 Child's health records; access to custodial and noncustodial parents](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-7.md)
- [Ind. Code § 16-39-1-8 Copying fees](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-8.md)
- [Ind. Code § 16-39-1-9 Alcohol and drug abuse records](https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-9.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_IN_T16_A39_C1_S16-39-1-4. Check the current official text before relying on it. Not legal advice.