Get University Of Michigan 2901 Hubbard Rd 2722 Ann Arbor Michigan 48109

This guide provides detailed instructions on how to complete the University Of Michigan’s affidavit of heir or life insurance beneficiary requesting medical records form online. Whether you are a requestor, an heir at law, or a beneficiary, this step-by-step approach will assist you in accurately filling out the required information.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the affidavit form, allowing you to fill it out online.
2. Begin by entering the deceased patient's name in the designated fields: last name, first name, and middle name. Ensure that the names are spelled correctly.
3. Fill in the address of the deceased patient, including street, city, state, and zip code.
4. Provide the birth date of the deceased patient using the format dd/mm/yyyy.
5. Input the name of the requestor in the corresponding fields, including last name and first name.
6. Enter the telephone number of the requestor, along with the Michigan area code.
7. Complete the address fields for the requestor: street, city, state, and zip code.
8. In the section labeled 'description of requested records and dates of service', provide any specific information regarding the medical records you are requesting.
9. In the affidavit section, indicate your relationship to the deceased patient by checking the appropriate box. Make sure to provide any required documentation as specified.
10. If claiming as an heir at law, complete the details in Section A and check the box that best describes your claim, ensuring to attach necessary documentation.
11. If you are the beneficiary of the deceased patient’s life insurance, complete Section B and provide relevant documentation, such as the Certificate of Coverage and your ID.
12. Sign the form, print your name, and ensure it is notarized. If signing by mark, additional witness signatures will be required.
13. After filling out all sections and verifying the information for accuracy, you can save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth and efficient process.