Indiana Code Title 34. Civil Law and Procedure § 34-43-1-7

(A) the full name of the patient;

(B) the patient's medical record number;

(C) the number of pages in the hospital medical record;  and

(D) a statement in substantially the following form:

“The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed hospital medical records that are housed in _______ (name of hospital).  The original records were made in the regular course of business, and it was the regular course of _______ (name of hospital) to make the records at or near the time of the matter recorded.  This certification is given under IC 34-43-1-5 by the custodian of the records instead of the custodian's personal appearance.”.