MICHIGAN DEPARTMENT OF CORRECTIONS – Bureau of Health Care Services
PATIENT’S AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
CHJ-121
9/14
Name: Number: D.O.B.
(PRINT
OR
TYPE
FULL
NAME
OF
PATIENT)
Information to be released from:
Facility: Address:
Information to be released to:
A
ddress
Organization (if applicable)
SPECIFIC DATES OF INFORMATION TO BE RELEASED:
Beginning Date: Ending Date:
Written Verbal
SPECIFIC INFORMATION: Medical Dental Mental Health Complete Health Record
Other – Specify:
Purpose of Release:
By signing this form I am attesting to the fact that the records I am requesting be released, and may include alcohol, substance
abuse, mental health status,
1
and serious infectious and communicable diseases (including venereal diseases, tuberculosis,
Hepatitis C, and HIV infection)
2
are protected under State of Michigan and Federal confidentiality regulations and cannot be
disclosed without my written consent unless otherwise provided for in the regulation.
I understand that I may revoke this authorization in writing at any time and that this authorization pertains to fulfillment of the
above stated request. No information collected beyond this date will be released unless it pertains to this request. This release
expires one year from the date of signature.
I have read the above and acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
I DO HEREBY CONSENT TO THE DISCLOSURE OF THE ABOVE DESCRIBED INFORMATION CONTAINED IN THE
HEALTH RECORD IDENTIFIED ON THIS FORM.
Date: PATIENT / MINOR’S PARENT / GUARDIAN / MEDICAL POWER OF ATTORNEY SIGNATURE
Date: WITNESS SIGNATURE
1 Prohibition of Redisclosure: This information has been disclosed to you from records whose confidentiality is protected by Federal and State Law.
Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of this information except with the specific written consent of the
person to whom it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose
(21 USC 1175; 42 USC 4582).
2 Michigan Public Health Code (MCL 333.1101 et seq.); Medical Records Access Act (MCL 333.26261 et seq.). 2014-2015 Appropriation Bill.
