Authorization To Release Copies Of A Medical Record Page 2
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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
6. This authorization expires on:
(specify expiration date or event).
If the expiration date is left blank, the authorization expires 60 days from the signature date.
7. Revoking (cancelling) authorization: I may revoke (cancel) this authorization at any time. Revocations (cancellations) must be
made in writing and sent to the UMHS Health Information Management Release of Information Unit at the address listed on this
form. Revocations (cancellations) will not apply to information that already has been released. If this authorization was obtained as
a condition of providing insurance coverage, the authorization will not apply to my insurance company to the extent the law provides
my insurer with the right to contest a claim under the policy, or the policy itself.
8. Note: Once information has been disclosed, UMHS can no longer protect it from further disclosure.
. Payment:
9
There will be fees associated with most record requests as outlined below.
Check here if you require a call for fee approval prior to us processing your records.
_________________________________________________________________________________
_____/_____/__________
Signature of Patient or Legally Authorized Representative (if patient is a minor or unable to sign)
DATE (mm/dd/yyyy)
_________________________________________________________________________________
Printed Name of Legally Authorized Representative (if patient is a minor or unable to sign)
Relationship to Patient:
Spouse
Parent
Next-of-Kin
Legal Guardian
DPOA for Healthcare (must attach proof of DPOA-HC)
Additional Information Regarding Your Request
Requesting medical records on behalf of another person
If you are requesting medical records for someone other than yourself, you may be required to provide additional documentation to
show that you have a legal right to request the record set. Examples of these documents include Letters of Representation,
Guardianship Papers, Affidavit of Heir at Law, etc. Please contact the Release of Information Unit at (734) 936-5490 to determine the
documentation that will be required to process your request.
Submitting requests & receiving record copies
- Requests for medical records may be:
Mailed to Health Information Management, Release of Information Unit at 2901 Hubbard Rd., RM 2722, Ann Arbor, MI
48109-2435.
Faxed to Health Information Management, Release of Information Unit at (734) 936-8571.
Submitted in person Monday-Friday 8:00 AM – 5:00 PM to the ROI Unit at Hubbard Road location noted above.
Our average turnaround time for processing requests is seven business days plus shipping time. Unless otherwise requested,
records will be sent through US Mail. Records needed for medical emergencies will be faxed directly to a physician or medical
facility. Please include your phone number on your request, in case we need to contact you for additional information. For questions
regarding requests for medical record copies, please contact: Health Information Management – Release of Information Unit
at (734) 936-5490.
Fees
are authorized annually by the State of Michigan Medical Records Access Act, P.A. 47 of 2004, MCL 333.26269. Some
records requested for legal, insurance, or personal use may require a prepayment. If your request requires pre-payment, a fee notice
will be sent to you upon processing of your request. Actual postage and Michigan State tax will be added to the fees outlined below.
Records fees will be billed as follows (plus actual postage):
Patient (paper copy):
Attorneys and Insurance Companies:
-Pages 1-75 No charge
-Clerical Fee of $23.42
-Pages 76-100 are $1.17 per page
-Pages 1-20 are $1.17 per page
-Pages 101-125 are $0.59 per page
-Pages 21-50 are $0.59 per page
-Pages 126 and up are $0.23 per page to a maximum of $100
-Pages 51 and up are $0.23 per page
Patient e-Delivery:
-Microfiche copies are $1.50 per page
-Pages 1-75 No charge
-Pages 76 and up are $0.23 per page to a maximum of $25.00
Patient Account delivery:
-No charge
Page 2 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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