Authorization To Release Copies Of A Medical Record
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1
2For Clinic Use Only:
University of Michigan Health System
Records sent from Clinic – please image
AUTHORIZATION
Health Information Management (HIM)
form to patient record
Release of Information (ROI) Unit
TO RELEASE COPIES OF
Mailed
Picked Up
Faxed
2901 Hubbard Rd #2722
Date Received: _______________________
Ann Arbor, Michigan 48109-2435
A MEDICAL RECORD
Date Processed: ______________________
Phone: (734) 936-5490
(Patient Requests Information To Be Sent From UMHS)
Processed By: ________________________
Fax: (734) 936-8571
Forwarding Request to ROI for processing
in its entirety
Please complete this form
so we can help you receive the information you are requesting.
1. This authorization is voluntary. I understand that the University of Michigan Health System (UMHS) will not base treatment,
payment, enrollment, or eligibility for benefits on my signing this document. Please see the second page for the fee notice.
Patient Name: _____________________________
: _________________________ Date of Birth: _________________
Maiden/AKA
Street Address: _________________________________________________ UMHS MRN (optional): _________________________
City/State/Zip: _________________________________________________
Telephone #: __________________________________
Email Address: ________________________________________________________
myself
2.
Myself: I request the UMHS to release my protected health information to
to the address listed above.
Select delivery method:
eDelivery
US Mail
Pick-Up from ROI Unit
Account
(secure web link)
3.
Other: I am the patient, or the legally authorized representative of the patient listed above and request the UMHS to release
my protected health information to:
1.
Individual/Person*: _______________________________ Company/Organization: ___________________________________
Street Address: _______________________________________________________________________________
City/State/Zip: _________________________________________________ Telephone #: _____________________________
Select delivery method:
Fax # (health providers - only if urgent): _____________________________
US Mail
eDelivery (only to attorneys): ____________________________________________
If this request is to send records to another health care provider, is this a change in your primary care doctor?
*
If yes, please initial for the change to be applied in your medical record.
__________________ (initials required)
4. Purpose of release/disclosure to other person/organization:
Reason for Disclosure
Recommended Record Set (as described in Section 5)
Continuation of Care/Transfer of Care
Package 1
Attorney/Legal
Package 2 for a selected date range
Insurance Company
Package 1 for a selected date range
Workman’s Compensation
Package 1 from date of incident
Other (specify): __________________________________________________________________________________________
5. Record set to be released to the party indicated above:
I request the following information be released, which may include: alcohol and drug abuse/treatment; psychological and social work
counseling; HIV, AIDS or ARC; communicable disease or infections, including sexually transmitted diseases, venereal disease,
tuberculosis and hepatitis; genetic information and demographic information, for the purposes and conditions designated on this form.
Package selections (as recommended in Section 4, more may be specified below):
Package 1: Key Clinical Written Documentation (includes, as applicable, history & physical, discharge summary, operative
reports, consults, outpatient visit notes, test reports, lab results, ER clinician notes) related to a specific incident, injury or illness
from ____/____/________ (mm/dd/yyyy) to ____/____/________ (mm/dd/yyyy). If no dates listed, for the past 24 months.
Package 2: All Clinical Written Documentation from ____/____/________ to ____/____/________ (includes, as applicable,
(mm/dd/yyyy)
(mm/dd/yyyy)
Package 1 contents along with nursing notes, flow sheets, medication administration records, physician orders, etc.).
Other selections: From Dates of Service: ____/____/________ to ____/____/________
(mm/dd/yyyy)
(mm/dd/yyyy)
Immunization Report
Billing Information (Released by Billing. For Billing request status, please call (800) 992-9475.)
Laboratory test result reports
Reports for Radiology/Other Diagnostic Testing
Films/Images (Released by Radiology. For Radiology request status, please call (734) 936-4517. Additional charges may apply.)
MRI
CT Scan
Ultrasound
X-Rays
Breast Imaging (Mammograms, Breast Ultrasound or MRI)
Pathology Slides (Released by Pathology. For Pathology request status, please call (800) 862-7284. Additional charges may apply.)
Other Records (Please specify): _________________________________________________________________________
Page 1 of 2
Authorization To Release Copies Of A Medical Record (Patient
VER: A/15
70-10015
MEDICAL RECORD
Requests Information To Be Sent From UMHS)
HIM: 05/15
Replaces: POD-0138
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