AUTHORIZATION TO RELEASE MEDICAL AND TREATMENT RECORDS
I agree to permit ________________________________ | ||
(name of state institution) | ||
to release a copy of the medical and treatment records of | ||
__________________ | to _________________________ | |
(patient's name) | (name of local agency | |
serving the needs of | ||
individuals with a developmental disability) | ||
______________ | ___________________________ | |
(date) | (signature) | |
___________________________ | ||
(address) | ||
__________________ | ___________________________ | |
(signature of individual | (relationship to patient if | |
securing release of | signature is not that of the | |
medical and treatment | patient) | |
records) |
to local agencies serving the needs of individuals with a developmental disability in the area in which the patient will reside before or at the time the patient is discharged.
IC 12-24-11-2
Pre-1992 Revision Citation: 16-14-28-1(b).