Medical Records

Requesting Medical Records

Obtaining Copies of Your Medical Records: Release of Information (ROI)

Records can be released to anyone that the patient authorizes (in writing). A valid authorization MUST contain the following information or the request will be returned:

  • Patient's full name and date of birth (list any other names the patient may have had
  • Hospital Medical Record number (if available)
  • Specific information being requested (e.g., type of report/information and dates of service, etc.)
  • Purpose for which the information may be disclosed (personal records, continuation of care, etc).
  • To whom the information is to be sent (name, address, phone, fax number)
  • Specify authorization's expiration date if desired (see Release of Information form below)
  • All authorizations are valid for one year unless otherwise requested or revoked by patient.
  • The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
  • Date of the signature.

Copy service fees may apply

Our allowable copy service fees are regulated and revised annually by the State of Michigan (


Click to download Release of Information form

Click to download Affidavit of Heir Requesting Medical Record form


Health Information Management Department (HIM)
6667 Main Street
Cass City, MI  48726
Phone: 989-912-6252
Fax: 989-872-4661

Medical Records Direct Email:

Monday-Friday: 8:00am - 4:30pm

(click for directions)


Notary Services by appointment - please call for more information.