Form 40223 - Request To Release Information December 1997

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INDIANA PROTECTION AND ADVOCACY SERVICES
REQUEST TO RELEASE INFORMATION
State Form 40223 (R2 / 12-97)
I hereby request that: _____________________________________________________________________________
who is the person or organization in custody of information, release the following information:
______________________________________________________________________________________________
pertaining to: ___________________________________________________________________________________
(Name of individual about whom information pertains)
date of birth of individual: __________________________________________________________________________
address: _______________________________________________________________________________________
______________________________________________________________________________________________
to: ____________________________________________________________________________________________
(Name of person or organization in need of information)
at: ____________________________________________________________________________________________
(Address of person or organization in need of information)
For the purpose(s) of: _____________________________________________________________________________
______________________________________________________________________________________________
with the understanding that this information will not be used or disclosed for purposes not specified above.
Signature of individual about whom information pertains or person authorized by statute
Date (month, day, year)
Printed name of signatory
Relationship of signatory to individual about whom information
Address of signatory
The patient's consent to release of mental health records is subject to revocation at any time, except to the extent
that action has been taken in reliance on the patient's consent.
This consent will expire one hundred and eighty days (180) from the date of signature, unless consent is revoked prior to
that date.

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