Visit our new Madison Heights location for Covid Testing:
30675 Stephenson Hwy
Madison Heights, MI 48071
Please call 248-619-4372 with any questions
If you are not a Surgeons choice surgical patient please call for approval before filling out registration form. We do not process all lab requests.
Recipient Name: First Name Last Name Address: Street Address Address Line 2 City State Zip Email: Email Phone: Area Code Phone Number Fax: (healthcare provider/facility only) Area Code Fax Number
• I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Health Information Management Department at the following address: 22401 Foster Winter Dr. Southfield, MI 48075. Revocation will not apply to information that has already been disclosed in response to this authorization. • Unless otherwise revoked, this authorization will expire (6) months from date of signature. Or upon the occurrence of the following date/event/condition: .• My health record may include information relating to sexually transmitted disease(s) (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of alcohol or drug abuse. • Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by the Federal Privacy Standards. • I may request that certain information about me not be released to third parties. Information that I wish not be shared is as follows: .• Third parties I wish not to share this information with include: .• Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.