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  • Records Release Form - Grand Rapids Women's Health

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Limited Patient Authorization for Disclosure of Protected Health Information Please print all information. Form must be signed and dated each year. Patient Name: SSN (last four digits): Date of Birth:.

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The creator of the medical record, not the patient, owns the medical record. Under Michigan law, private physicians and health care facilities are required to maintain their medical records in a manner that protects the confidentiality of the records and assures accessibility to the information when required.

Paper copies: $1.22 per page for the first 20 pages. $0.61 per page for pages 21 through 50.

(a) An initial fee of $20.00 per request for a copy of the record.

Unless a longer retention period is otherwise required under federal or state laws or regulations or by generally accepted standards of medical practice, a licensee shall keep and retain each record for a minimum of 7 years from the date of service to which the record pertains.

If you have an urgent need to get copies of your medical records, please call the Release of Information Unit at 734-936-5490 Monday through Friday from 8am – 5pm or fax your request to 734-936-8571.

Generally, competent adult patients have the right to access their own medical records, see MCL 333.26265(1). Minors who have the right to consent to treatment without a parent are also considered to be a “patient” and have the right to access his or her medical record.

The records shall be maintained in such a manner as to protect their integrity, to ensure their confidentiality and proper use, and to ensure their accessibility and availability to each patient or his or her authorized representative as required by law.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232