Release of Information

RECORD SETS:

CLINIC (OFICE VISIT NOTES, LABS, RADIOLOGY, MEDICINES, IMMUNIZATIONS) HOSPITAL (HISTORY & PHYSICAL, DISCHARGE SUMMARY, OPERATIVE REPORT, CONSULTATION, ER, LAB, RADIOLOGY)

ONLY RECORD TYPES INDICATED BELOW FOR DATES OF SERVICE LISTED ABOVE:

PUROSE OF RELEASE: (* INDICATES PAYMENT REQUIRED)

BY SIGNING THIS FORM, I UNDERSTAND THAT:

I do not have to sign this authorization.

This form expires 60 days after the date of signature unless otherwise specified here: Date of Expiration:

A third party medical records retrieval service may be used for this medical record request (Healthcare Technologies)

Other types of information shared under this authorization may be re-disclosed by the person or organization I identified above and may no longer be protected by federal or state law.

I may change my mind and revoke (take back) this authorization at any time. To revoke this authorization, contact MICHIGAN CLINIC NEUROSURGERY at 989-799-8712.

Information that has already been shared based on this authorization cannot be taken back.

I may request a copy of this signed authorization. If I have not previously revoked this authorization, it will expire on: (list a date, event or condition)

FEES are authorized and updated annually by the State of Michigan Medical Records Access Act, P.A. 47 of 2004, MCL333.23239. Additional fee guidance can be provided under federal regulations, contact HEALTHCARE TECHNOLOGIES (810-720-3136). 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 receipt of your request. There is NO charge if records are sent directly to your doctor to continue your care or for records obtained through your Patient Portal.

MICHIGAN CLINIC NEUROSURGERY

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

PATIENT INFORMATION:

CLINIC/HOSPITAL/PROVIDER - (Who had the information you want released):

RECEIVING PARTY -- (Where do you want the information sent):

INFORMATION TO BE RELEASED - (WHAT DO YOU WANT SENT OR RELEASED):

BY SIGNING THIS FORM, I UNDERSTAND THAT:

Release of Information

MICHIGAN CLINIC NEUROSURGERY

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

PATIENT INFORMATION:

CLINIC/HOSPITAL/PROVIDER - (Who had the information you want released):

RECEIVING PARTY -- (Where do you want the information sent):

INFORMATION TO BE RELEASED - (WHAT DO YOU WANT SENT OR RELEASED):

BY SIGNING THIS FORM, I UNDERSTAND THAT:

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