Release of Information

The form below is our Release of Information Form.

Fields with an * are required.

Step 1 of 2
Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
1. INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION
(Sr., Jr., etc)
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.)
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 disclosing information, enter your provider's name and/or our organization's name, i.e, Michael Frampton, M.D., P.C.)
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: Physician/facility name for records OR Employer name or department, like HR, for FMLA & Disability forms.)