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:

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