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.

Name (type or print) (If signing as Personal Representative, please state
under what authority you are acting)

City, state, zip                                                                             Telephone no.

Address

 

 

ate

  D

Signature

Plaintiff

Defendant

v

 

Date of birth

 Probate    In the matter of 
 

1. 

Patient’s name

2. I authorize 

to release 

 

 

 

 

 

 

to 

Name and address of doctor, hospital, or other custodian of medical information

Description of medical information to be released (include dates where appropriate)

MC 315 (6/17) AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION45 CFR 164.508, MCL 333.5131(5)(d), MCR 2.506(l)(1)(b), MCR 2.314Approved, SCAO Original - Records custodian1st copy - Requesting party2nd copy - PatientSTATE OF MICHIGANJUDICIAL DISTRICT JUDICIAL CIRCUITCOUNTY  PROBATEAUTHORIZATION FOR RELEASEOF MEDICAL INFORMATIONCASE NO.Court addressCourt telephone no.Authorization for Release of Medical Information

 

(6/17) Page 
 

  

 of 

  

CERTIFICATE

Case No. 
 

1. I am the custodian of medical information for 

 

Organization

 .

2. I received the attached authorization for release of medical information on 

 

 .

Date

 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

Address

Name (type or print)

City, state, zip                                                                             Telephone no.