Authorization For Disclosure Of Protected Health Information And Other Information
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AUTHORIZATION FOR DISCLOSURE OF PROTECTED
HEALTH INFORMATION AND OTHER INFORMATION
State Form 40223 (R4 / 7-09)
INDIANA PROTECTION AND ADVOCACY SERVICES COMMISSION
I authorize the disclosure of the protected health information and other information (as described below) of the individual
identified below:
Name of individual (printed)
Date of birth (month, day, year)
Address (number and street, city, state, and ZIP code)
I authorize the person or organization specified below to disclose the protected health information and other information of the
individual to Indiana Protection and Advocacy Services or any of its employees upon request in person or by mail to the
address specified at the time of the request.
Name of person or organization in possession of the information
Address (number and street, city, state, and ZIP code)
Specific description of the protected health information and other information that I authorize for disclosure: Information and
individual records, whether written or in another medium, draft or final, including handwritten notes, electronic files, photographs
or video or audio tape records, including the following (check applicable boxes):
Records prepared or received in the course of providing intake, assessment, treatment, discharge planning, evaluation,
education, training and other supportive services, including medical records, financial records, and monitoring and other
reports prepared or received by an employee or agent of the person/organization specified above.
Reports prepared by an agency charged with investigating incidents of abuse or neglect occurring on the premises of the
person/organization specified above or while the individual is under the care of an employee or agent of the organization
specified above, that describe any or all of the following: (1) Abuse, neglect; (2) The steps taken to investigate the incidents;
(3) Reports and records prepared or maintained by the facility in connection with such reports or incidents; or (4) Supporting
information that was relied upon in creating a report, including all information and records which describe persons who were
interviewed, physical and documentary evidence that was reviewed, and the related investigative findings.
Complaints or grievances filed, with responses or dispositions.
Other:
The following records are specifically NOT to be disclosed under this authorization (if applicable):
The information is being used/disclosed for the following purpose: At the request of the individual.
State Form 40223,
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