Medical Records Forms

Authorization for Release of Information

Request for Medical Records Billing Sheet

Title 760 Department of Insurance


The form "Authorization of Release of Information" must be completed, signed and dated for the release of any medical records from Nephrology Physicians, LLC.

We conform to all laws in accordance to confidentiality, belonging to the patient or entity mentioned by the patient that is legally privileged.

If medical records are requested we do have the option to charge a nominal fee. Please see the section Title 760 Department of Insurance.


For Further Information, contact:

Hemodialysis Patients Contact: –The unit secretary where you dialyze

Edison Lakes (574) 273-6776
Blackthorn (574) 246-7000
LaPorte (219) 324-0944
Elkhart (574) 294-4444

CAPD Patients – Contact: The CAPD Secretary - Connie at (574) 273-6777 ext. 1210

Deceased Patient Information Requests, Office Patients, Legal, Disability or Insurance – Contact: Medical Records Coordinator – Cindy (574) 273-6787 ext 1207