Release of Information Form

The form below is our Release of Information Form.

Fields with an * are required.

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
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 sending information, enter your doctor/therapist name and/or our business name. i.e. Michael Frampton MD, PC below.)
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.)
Describe each purpose for which you are authorizing your protected health information to be used and/or disclosed.
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 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.) Date format like this please: 00/00/0000
(If no date is specified above, I understand this authorization will expire in 60 days from the date below).
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