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