to Release
Protected Health Information
University Health Service
Health Information Management (HIM)
207 Fletcher St., Ann Arbor, MI 48109-1050
Phone 734-936-3275, Fax 734-936-3063
Email UHS-ROIRequest@med.umich.edu
Patient name: Last: First: Maiden:
Medical record # if known: Date of birth: U-M ID #:
Current address: City: State: Zip:
Telephone #: Last 4 digits of Social Security #:
Release information FROM (check only one box):
University Health Service (address above)
Other (specify facility/individual, address, phone, fax)
Myself
University Health Service (address above)
Other (specify facility/individual, address, phone,
fax)
Date(s) of treatment: From (start date): To (end date):
I request the following information to be released, which may include alcohol and drug abuse/treatment; psychological and social work counseling; HIV or AIDS or
ARC; communicable disease or infections, including sexually transmitted diseases, venereal disease, tuberculosis and hepatitis, and demographic information, for
the purposes and conditions designated on this form. A request for an entire health record does not routinely include records sent to UHS from a previous health
care provider.
Visit notes Immunizations Lab results Weight Mental health Eye care
Physical therapy Radiology report Radiology images
Pap result STI-related Women’s health
Medication, evaluation, diagnosis & treatment plan Other (specify):
Partial health record, which contains immunizations, two (2) years of office visit and lab information, and five (5) years of radiology and
diagnostic reports. This is sufficient to meet the needs of many requests, including transferring your care to a new provider.
Purpose for this disclosure (optional): Personal Insurance Consultation Continuing medical treatment
Other:
Delivery: Pick-up US Mail MyUofMHealth.org (for records from UHS created after 6/2012)
eDelivery (secure web link) – only available for UHS records created after 6/2012; provide email:
Other:
Revocation: I understand that I have the right to revoke this authorization at any time by writing to the address above. This authorization shall remain valid until
revoked or upon the expiration date/event specified below, whichever occurs first. After it is revoked or expired, UHS will make no further disclosures to the above
persons without a new authorization. A request to revoke my authorization will not apply to the extent that UHS has taken action in reliance upon my authorization.
Redisclosure: Once information has been disclosed, UHS can no longer protect it from further disclosure.
Conditioning of Eligibility: UHS will not condition treatment, payment, and enrollment or benefit eligibility on my signing this document.
This authorization shall remain valid for 60 days unless you specify an additional time period, up to a maximum of 12 months.
Other expiration date
Signature (Electronic signature NOT accepted) Printed Name of Signer (First Last) Date of Signature
If signed by other authorized person, Relationship to Patient:
For Health Service Use Only
Request received: In person Written form Telephone Fax eDelivery
Identity verified by: U-M ID Driver license Signature Other:
Information to be: Mailed Picked up/date needed: Faxed eDelivery Portal
Request completed by: HIM staff initials/date: Other staff initials/date:
Confidential information – To be used only for the purpose(s) requested ROI Rev 9-2020
