MC 315 (6/17) AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
45 CFR 164.508, MCL 333.5131(5)(d),
MCR 2.506(l)(1)(b), MCR 2.314
Plaintiff
v
Defendant
Probate In the matter of
Approved, SCAO
Original - Records custodian
1st copy - Requesting party
2nd copy - Patient
STATE OF MICHIGAN
JUDICIAL DISTRICT
JUDICIAL CIRCUIT
COUNTY PROBATE
AUTHORIZATION FOR RELEASE
OF MEDICAL INFORMATION
CASE NO.
Court address Court telephone no.
1.
Patient’s name
Date of birth
2. I authorize
Name and address of doctor, hospital, or other custodian of medical information
to release
Description of medical information to be released (include dates where appropriate)
to
Name and address of party to whom the information is to be given
3. I understand that unless I expressly direct otherwise:
a) the custodian will make the medical information reasonably available for inspection and copying, or
b) the custodian will deliver to the requesting party the original information or a true and exact copy of the original
information accompanied by the certificate on the reverse side of this authorization.
I understand that medical information may include records, if any, on alcohol and drug abuse, psychology, social work,
and information about HIV, AIDS, ARC, and any other communicable disease.
4. This authorization is valid for 60 days and is signed to make medical information regarding me available to the other
party(ies) to the lawsuit listed above for their use in any stage of the lawsuit.The medical information covered by this release
is relevant because my mental or physical condition is in controversy in the lawsuit.
5. I understand that by signing this authorization there is potential for protected health information to be redisclosed by the
recipient.
6. I understand that I may revoke this authorization, except to the extent action has already been taken in reliance upon this
authorization, at any time by sending a written revocation to the doctor, hospital, or other custodian of medical information.
Date
Signature
Address
Name (type or print) (If signing as Personal Representative, please state
under what authority you are acting)
City, state, zip Telephone no.
Authorization for Release of Medical Information (6/17) Page
of
Case No.
Organization
1. I am the custodian of medical information for .
Date
2. I received the attached authorization for release of medical information on .
3. I have examined the original medical information regarding this patient and have attached a true and complete copy of the
information that was described in the authorization.
4. This certificate is made in accordance with Michigan Court Rule.
I declare that the statements above are true to the best of my information, knowledge, and belief.
Date Signature
Name (type or print)
Address
City, state, zip Telephone no.
CERTIFICATE
