Medical Records Authorization (HIPAA)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (INDIANA)

This Authorization complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. § 164.508, and applicable Indiana law.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following provider(s), facility(ies), and their business associates to release my protected health information ("PHI"):

3. RECIPIENT(S) — WHO MAY RECEIVE THE RECORDS

4. RECORDS / INFORMATION TO BE RELEASED

☐ Complete health record
☐ Only records for the following date range: [__/__/____] to [__/__/____]
☐ Only records relating to the following incident/condition: [________________________________]

Record types (check all that apply):

☐ History and physical / office notes
☐ Physician and nursing notes
☐ Hospital / emergency-department records
☐ Diagnostic imaging (X-ray, MRI, CT) and reports
☐ Laboratory and pathology results
☐ Operative and procedure reports
☐ Physical therapy / rehabilitation records
☐ Prescription and medication records
☐ Itemized billing statements and insurance records
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

This disclosure is made at the request of the patient for the following purpose: evaluation, investigation, prosecution, and settlement of the patient's personal-injury claim, including legal representation.

☐ Other purpose: [________________________________]

6. HIPAA CORE-ELEMENT RECITALS

6.1 Expiration. This Authorization expires on the earlier of: (a) [__/__/____]; (b) the following event: [final resolution of the personal-injury claim]; or (c) if no date or event is stated, two (2) years from the date of signature. (Note: under Ind. Code § 16-39-2-5, a mental-health records request is valid for 180 days unless otherwise specified.)

6.2 Right to Revoke. I may revoke this Authorization at any time by written, signed notice to the provider, except to the extent action has already been taken in reliance on it.

6.3 No Conditioning. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. Information disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Indiana law.

6.5 Copy. I am entitled to a copy of this signed Authorization.

7. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

I specifically authorize release of the following protected categories (initial each that applies; a blank line means that category is NOT authorized):

42 C.F.R. Part 2 prohibition on redisclosure (SUD records). This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of information that identifies a patient as having or having had a substance use disorder unless further disclosure is expressly permitted by the written consent of the individual or as otherwise permitted by 42 C.F.R. Part 2. A general authorization is NOT sufficient for this purpose (see 42 C.F.R. § 2.31).

8. INDIANA MENTAL HEALTH RECORDS RELEASE (Ind. Code § 16-39-2-5)

Complete this section ONLY if mental-health records are authorized in Section 7. A request for mental-health records must include each of the following:

Statement (item 8): My consent to release mental-health records is subject to revocation at any time, except to the extent that action has been taken in reliance on this consent.

9. COPY FEES AND RESPONSE TIME (INDIANA)

Under Ind. Code § 16-39-1-1, on written request and reasonable notice a provider must supply a copy of the patient's health record within thirty (30) days, subject to one written extension of not more than thirty (30) additional days for which the provider must state the reason in writing. Copying fees are governed by Ind. Code § 16-39-9 (statutory per-page schedule, plus labor/retrieval and postage where allowed). A provider may be fined up to $5,000 for noncompliance. Mental-health records are governed by Ind. Code art. 16-39, ch. 2; communicable-disease/HIV records by Ind. Code § 16-41-8; and SUD records by 42 C.F.R. Part 2.

10. SIGNATURE

Personal representative (if patient is a minor, incapacitated, or deceased):

11. NOTARY (OPTIONAL)

State of Indiana, County of [________________]

Subscribed and sworn before me this [____] day of [____________], 20[____].

Notary Public: ________________________________ My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• Ind. Code § 16-39-1-1 — Right of access; written requests; deadline: https://law.justia.com/codes/indiana/title-16/article-39/chapter-1/section-16-39-1-1/
• Ind. Code § 16-39-2-5 — Release of mental health records: https://codes.findlaw.com/in/title-16-health/in-code-sect-16-39-2-5/
• Ind. Code art. 16-39, ch. 9 — Fees for copying health records: https://law.justia.com/codes/indiana/title-16/article-39/chapter-9/
• Ind. Code § 16-41-8 — Communicable disease records: https://law.justia.com/codes/indiana/title-16/article-41/chapter-8/