Transcription of CHILDREN’S PROTECTIVE SERVICES REQUEST FOR …
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CHILDREN’S PROTECTIVE SERVICES REQUEST FOR …
[ N a m e ] C o u n t y B o a r d : [ B o a r d M e m b e r N a m e s ] [ A D D R E S S ] [ C I T Y ] , M I C H I G A N [ Z i p C o d e ] [PhoneN u m b e r ] DHS-1163-M (Rev. 2-09) MS Word 1 STATE OF michigan DEPARTMENT OF HUMAN SERVICES CHILDREN S PROTECTIVE SERVICES REQUEST FOR medical INFORMATION Case Name TO: Case Number County District Section Unit Worker Concerning Family/Household Members Date(s) of Birth There is a compelling need for the medical records held by you or your agency, pertinent to a Children s PROTECTIVE SERVICES (CPS) investigation on the family/household member(s) identified abov
DHS-1163-M (Rev. 2-09) MS Word 3 Michigan Public Health Code, 1978 PA 368, MCL 333.2640 and 333.16281 MCL 333.2640 (2) Notwithstanding section 2637, if there is a compelling need for medical records or information to
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