Release of Information | Michael Frampton, M.D. & Associates

Release of Information Form

The form below is our Release of Information Form.

Fields with an * are required.

Release of Information

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Check this box if this authorization is a medical records request for personal use only, and this authorization may not be used for any other purpose.

Yes

1. INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION

First Name

Middle Initial

Last Name

Suffix (Sr, Jr, etc.)

Date of Birth:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

2. THE USE AND/OR DISCLOSURE AUTHORIZED
(Call us if you have any questions while completing this section.)

Describe in detail the protected health information you are authorizing to be used and/or disclosed. (* Examples: Medical Records, FMLA Forms, any relevant medical information.)

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Name the people and/or organizations (or the kinds of people and/or organizations) that you are authorizing to DISCLOSE the protected health information described above. (* Example: if we are sending information, enter your doctor/therapist name and/or our business name. i.e. Michael Frampton MD, PC below.)

Textarea

Name the people and/or organizations (or the kinds of people and/or organizations) that you are authorizing to RECEIVE and use the protected health information described above. (* Example: list the person(s) and/or place(s) where we are sending your forms/information to below.)

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Describe each purpose for which you are authorizing your protected health information to be used and/or disclosed.

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Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION - PART 2

3. ENDING THIS AUTHORIZATION

This authorization will automatically end 60 days from the date of your signature at the end of this form. If you prefer to end the authorization on a different date, enter the date in the field below. DO NOT ENTER TODAY'S DATE. Enter a FUTURE date from today. Please use the date format of 00/00/0000.

This authorization will end on the following date: (Unless you are picking something today, do not enter today's date. Please enter a future date that allows for sufficient processing time.)

4. CHANGING YOUR MIND ABOUT THIS AUTHORIZATION

I understand that I may revoke this authorization at any time by giving written notice to Michael Frampton, M.D., P.C. However, I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

5. SIGNING THIS AUTHORIZATION IS NOT A CONDITION OF TREATMENT

I understand that under most circumstances a healthcare provider may not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. However, I understand that signing an authorization that permits the use and/or disclosure of my protected information for research purposes may be a condition of my treatment if I am undergoing research-related treatment. Also, I may be required to sign an authorization if my treatment is provided solely for the purpose of creating protected health information for disclosure to a third party. And under some circumstances, a health plan may condition my enrollment in a health plan or my eligibility for benefits on my providing an authorization permitting the health plan to make enrollment and eligibility determinations.

6. RE-DISCLOSURE OF INFORMATION

I understand that information used or disclosed pursuant to this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

7. PATIENT SIGNATURE

Patient Signature

Today's Date:

Relationship to Patient:

Guardian Disclaimer

I understand I will need to submit proof of Guardianship

Power of Attorney Disclaimer

I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient here:

Email:

Release of Information Form

Contact Us:

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