Submit the completed form to Henry Ford Macomb Hospitals via mail to 15855 Nineteen Mile Road, Clinton Twp., MI 48038, fax at (586) 263-2446, or email to the designated department. Ensure all required fields are completed, and the form is signed and dated. For further assistance, contact the hospital at (586) 263-2470. It is advisable to keep a copy of the completed form for your records.

The form must be submitted within six months of the request date to remain valid. Ensure all disclosures and authorizations are completed within this timeframe.

The purpose of this form, 'Authorization to Release Medical Information,' is to facilitate the secure and authorized transfer of a patient's medical records from Henry Ford Health Systems to the designated recipient. This form plays a critical role in maintaining the continuum of care, ensuring that healthcare providers have access to important medical information necessary for effective treatment and management of patient health. It also supports various administrative functions such as insurance claim processing and legal requests, streamlining the process of information sharing in compliance with federal privacy regulations. By completing and submitting this form, patients grant explicit consent for the release of their medical information, empowering them to control who has access to their sensitive health records.

• 1. patientName: The patient's full name, including any maiden or other names the patient is known by.
• 2. address: The patient's complete address including street, city, state, zip code, and phone number with area code.
• 3. ssn: The patient's social security number for identification purposes.
• 4. recipientInfo: Information of the recipient including name, organization, and their address and contact details.
• 5. infoToRelease: Specific information to be released such as medical records, test results, hospitalization details, and more.
• 6. purposeOfDisclosure: The reason for the information release, with options including treatment, insurance, legal, and other purposes.
• 7. specialInfo: Check boxes for including sensitive information such as substance abuse records, mental health treatment, and communicable diseases.
• 8. expirationDate: The expiration date of the authorization, typically set to six months from the request date unless revoked earlier.
• 9. signature: Signature of the patient or their representative, along with the date and relationship to the patient.
• 10. witnessSignature: Signature of a workforce member (witness) to validate the authenticity of the patient's signature.

Failure to submit this form can result in delays or the inability to transfer medical information as needed.

• Treatment Delay: Your healthcare provider may not receive important medical information in a timely manner, hindering your treatment.
• Insurance Issues: Insurance claims may be delayed or denied without the necessary medical records.
• Legal Complications: Legal requests for medical records may not be fulfilled, potentially impacting legal proceedings.
• Denied Benefits: Applications for disability or other benefits may be denied without the required medical information.

• 1. Continued Medical Care: When transferring to another healthcare provider for ongoing treatment.
• 2. Insurance Claims: When an insurance company requires medical records for claim evaluation.
• 3. Legal Requests: When an attorney requests medical records for a legal case.
• 4. Disability Benefits: When applying for disability benefits that require submission of medical records.
• 5. Personal Records: When a patient wants a personal copy of their medical records for their own use.