Recipient Name:   First Name   Last Name  
Recipient Address:   Street Address    Address Line 2   City       State   Zip       
Email:   Email    Phone:      Phone Number   
Fax: 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:   Fill .
• 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. 

I UNDERSTAND THAT I MAY INCUR FEES FOR RECEIVING COPIES OF MY MEDICAL RECORDS. FEES FOR COPIES OF MEDICAL RECORDS ARE REGULATED BY THE STATE OF MICHIGAN.