• 5333 McAuley Drive
    Reichert Health Building
    Suite 5115
    Ypsilanti, MI 48197
    734.434.4430
    www.annarborendo.com

  • PATIENT AUTHORIZATION FOR DISCLOSURE OF HEALTH CARE INFORMATION

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  • I request and authorize Ann Arbor Endocrinology & Diabetes Associates, P.C. to release health care information of the patient named above to:

  • This request and authorization applies to:

  • This information will be disclosed to facilitate patient’s personal health care or be used as a part of review of patient’s health (i.e. employers, workers’ compensation, social security agencies, disability claims, life of health insurance claims, or in cases of medical-legal matters/disputes). You are not required to identify specific reasons for disclosing/releasing health care information unless you feel it will facilitate your health care.

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  • Should be Empty: