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 the 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. www.michigan.gov
Notary Services by appointment
Please call for information.
Health Information Management Department (HIM)
6667 Main Street
Cass City, MI 48726
Medical Records Direct Email: firstname.lastname@example.org
Monday-Friday: 8:00 am - 4:30 pm