Ind. Code § 12-24-11-2
| 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) | ||
(e) If a patient knowingly signs the form for the release of medical records under subsection (d), a service coordinator employed by the division of disability and rehabilitative services under IC 12-11-2.1 shall allow local agencies serving the needs of individuals with a developmental disability in the area in which the patient will reside to obtain the following:
(g) If a patient does not agree to permit the release of the patient's medical and treatment records, the service coordinator shall deliver:
(2) the address of the patient's intended residence;
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.
[Pre-1992 Revision Citation: 16-14-28-1(b).]
As added by P.L.2-1992, SEC.18. Amended by P.L.4-1993, SEC.200; P.L.5-1993, SEC.213; P.L.24-1997, SEC.55; P.L.272-1999, SEC.45; P.L.141-2006, SEC.65; P.L.99-2007, SEC.117.