Indiana Code Title 16. Health § 16-39-1-4

(1) The name and address of the patient.

(2) The name of the person requested to release the patient's record.

(3) The name of the person or provider to whom the patient's health record is to be released.

(4) The purpose of the release.

(5) A description of the information to be released from the health record.

(6) The signature of the patient, or the signature of the patient's legal representative if the patient is incompetent.

(7) The date on which the consent is signed.

(8) A statement that the consent is subject to revocation at any time, except to the extent that action has been taken in reliance on the consent.

(9) The date, event, or condition on which the consent will expire if not previously revoked.