Fillable Printable Authorization To Release Copies Of a Medical Record
Fillable Printable Authorization To Release Copies Of a Medical Record
Authorization To Release Copies Of a Medical Record
University of Michigan Health System
Health Information Management (HIM)
Release of Information (ROI) Unit
2901 Hubbard Rd #2722
Ann Arbor, Michigan 48109-2435
Phone: (734) 936-5490
Fax: (734) 936-8571
AUTHORIZATION
TO RELEASE COPIES OF
A MEDICAL RECORD
(Patient Requests Information To Be Sent From UMHS)
For Clinic Use Only:
Records sent from Clinic – please image
form to patient record
Mailed Picked Up Faxed
Date Received: _______________________
Date Processed: ______________________
Processed By: ________________________
Forwarding Request to ROI for processing
Page 1 of 2
70-10015
VER: A/15
HIM: 05/15
MEDICAL RECORD
Authorization To Release Copies Of A Medical Record (Patient
Requests Information To Be Sent From UMHS)
Replaces: POD-0138
Please complete this form in its entirety 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: _____________________________ Maiden/AKA: _________________________ Date of Birth: _________________
Street Address: _________________________________________________ UMHS MRN (optional): _________________________
City/State/Zip: _________________________________________________ Telephone #: __________________________________
Email Address: ________________________________________________________
2. Myself: I request the UMHS to release my protected health information to myself to the address listed above.
Select delivery method: eDelivery (secure web link) US Mail Pick-Up from ROI Unit MyUofMHealth.org Account
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): _________________________________________________________________________
University of Michigan Health System
Health Information Management (HIM)
Release of Information (ROI) Unit
2901 Hubbard Rd #2722
Ann Arbor, Michigan 48109-2435
Phone: (734) 936-5490
Fax: (734) 936-8571
AUTHORIZATION
TO RELEASE COPIES OF
A MEDICAL RECORD
(Patient Requests Information To Be Sent From UMHS)
For Clinic Use Only:
Records sent from Clinic – please image
form to patient record
Mailed Picked Up Faxed
Date Received: _______________________
Date Processed: ______________________
Processed By: ________________________
Forwarding Request to ROI for processing
Page 2 of 2
70-10015
VER: A/15
HIM: 05/15
MEDICAL RECORD
Authorization To Release Copies Of A Medical Record (Patient
Requests Information To Be Sent From UMHS)
Replaces: POD-0138
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.
9. Payment: 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 MyUofMHealth.org Account delivery:
-No charge
