Get Authorization To Request - Med Umich
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Authorization To Request - Med Umich online
Filling out the Authorization To Request form from the University of Michigan is a straightforward process that allows users to request outside medical records. This guide provides clear and step-by-step instructions to ensure that you complete the form accurately and efficiently.
Follow the steps to complete your request for medical records.
- Select the 'Get Form' button to access the Authorization To Request form online and open it in your preferred editing tool.
- Begin by completing the patient details section. Enter the patient's full name, maiden or known aliases, and the date of birth. Be sure to include the street address along with city, state, and zip code, as well as the telephone number and email address.
- Next, enter the University of Michigan Health System (UMHS) Medical Record Number, if available. This information helps facilitate the retrieval of medical records.
- In the 'I hereby authorize the release of information from' section, provide the name of the person or organization from which records will be requested, including their street address and city, state, and zip code.
- Specify the UMHS clinic or unit where the information should be sent. Include details such as the name, address, and telephone number of the clinic or unit, as well as the fax number if required.
- Indicate the specific information that you need by checking the relevant boxes. You may select multiple options, such as inpatient records, laboratory test results, or entire medical records. Additionally, you can specify other types of records if needed.
- For the purpose of release section, check the appropriate box to confirm whether the request is at the patient's own request or for continued care.
- Indicate the expiration date for this authorization, if desired. If left blank, it will automatically expire six months after the date you sign the form.
- Acknowledge your rights regarding the revocation of this authorization. You may revoke this authorization at any time by providing a written request to the releasing organization.
- Sign and date the form. If a legally authorized representative is signing, be sure to print their name and specify their relationship to the patient.
- Once all sections are completed, review the information for accuracy. You can then save your changes, download the filled form, print it for records, or share it as required.
Complete your Authorization To Request - Med Umich form online now to ensure a smooth process for obtaining your medical records.
To give someone access to your medical records, you will need to use the Authorization To Request - Med Umich form. This form requires your information and the details of the person you are allowing access. Once you fill out the form and submit it to your provider, they will facilitate the sharing of your records as authorized. Make sure to check with your provider for any additional steps or requirements.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.