Records Request Form

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

Patient’s Name: *

Date of Birth: *

Previous Name (or previous name upon which health care was provided)

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

Name or organization: *

Address:*

Street Address

CityState

Zip Code

This request and authorization applies to:

Health care information relating to the following treatment, condition, or dates of treatment:

All health care information (excludes billing)

Other:

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.

Patient Signature*

Date*

Date