Authorization For Disclosure Of Protected Health Information And Other Information Page 2

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I understand that:
•
If this information is no longer subject to federal and state information privacy laws, IPAS may re-disclose the
information.
•
This authorization expires 180 days from the date I sign this Authorization. I can revoke this authorization at
any time by giving written notice to Indiana Protection and Advocacy Services, 4701 N. Keystone Avenue,
Suite 222, Indianapolis, Indiana, 46205.
•
Revoking this authorization will not affect disclosures made or actions taken before the revocation is received
by Indiana Protection and Advocacy Services.
•
I am entitled to a copy of this authorization.
•
A copy of this authorization may be utilized with the same effectiveness as the original.
Signed name
Date (month, day, year)
Printed name
Check box if applicable:
The individual authorizing this disclosure is the guardian, conservator, or other legal representative of the individual and is
authorized to consent to the disclosure of that individual’s protected health information or other information. Legal
representative should attach documentation of authority, if available.
 
 
State Form 40223,
Page 2 of 2
 
 

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