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

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, For Personal Use Only

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

Patient's First Name: *

Patient's Middle Initial:

Patient's Last Name *

Suffix:

(Sr., Jr., etc)

Date of Birth: *

Address: *

City: *

State: *

Zip: *

Phone *

Confirm Email

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.)

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

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.)

(If no date is specified, 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

I have had the chance to read and think about the content of this authorization form and I agree with all statements made in this authorization. I understand that by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described in this form with the people and/or organizations named in this form.

Patient Signature: *

Date: *

Relationship to Patient:

Comment

Release of Information

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