[vc_row][vc_column][vc_column_text]Please read the instructions on this page.

Next, print and complete the Authorization to Use or Disclose Protected Health Information form when requesting copies of records.

Areas to be completed:

• Patient’s Name
• Medical Record Number (can be left blank if unsure)
• Account Number (can be left blank if unsure)
• Date of Birth
• Date of Service (approximate if unsure)

#1:  Fill in as Memorial Healthcare
#2:  Fill in type of records requested – example:  lab, x-ray, x-ray film, etc.
#4:  Fill in name of person who will be picking up the record(s)
#5:  Fill in where records will be taken – example:  another physician, insurance, personal file

Patient or Legal Guardian must sign and date in the area provided (signature of patient or legal guardian required) and initial at I hereby acknowledge receipt of this authorization. Copy of legal guardianship papers must accompany signed Authorization.

Someone will need to witness the patient’s signature and sign/date in the area provided (signature of witness required).

Please do not attempt to e-mail this form. The original form must be presented to or mailed to the Health Information Management Department at Memorial Healthcare (826. W. King, Owosso, MI 48867).

If you have any questions please call:  (989) 729-4503.[/vc_column_text][/vc_column][/vc_row]