Transcription of AUTHORIZATION TO RELEASE COPIES OF A MEDICAL RECORD
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AUTHORIZATION TO RELEASE COPIES OF A MEDICAL RECORD
michigan medicine health Information Management (HIM) RELEASE of Information (ROI) Unit 2901 Hubbard Rd #2722 Ann Arbor, michigan 48109-2435 Phone: (734) 936-5490 Fax: (734) 936-8571 AUTHORIZATION TO RELEASE COPIES OF A MEDICAL RECORD (Patient Requests Information To Be Sent From UMHS) For Clinic Use Only: Records sent from Clinic please send form to Central Imaging Mailed Picked Up Faxed Date Received: _____ Date Processed: _____ Processed By: _____ Forwarding Request to ROI for processing Page 1 of 2 70-10015 VER: B/18 HIM: 07/19 MEDICAL RECORD HIM ROI AUTHORIZATION Replaces: POD-0138 Please complete this form in its entirety so we can help you receive the information you are requesting. AUTHORIZATION is voluntary.
How do I get electronic or paper copies of my health records? Record Connect is the approved vendor that provides copies of medical records for Michigan Medicine patients and families. What is the cost? Medical Records Released Type of record Cost Directly to the Patient Electronic Record Delivered electronically $6.50 Directly to the Patient
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