Authorization for Release of Medical Information

Authorization for Release of Medical Information
Grace Health
181 West Emmett Street
Battle Creek MI, 49037
Telephone Number: (269) 965-8866 | Fax Number: (269) 966-2627
Email: hidnoreply@gracehealthmi.org
Patient Name*

First NameMiddle NameLast Name
Previous Name(s)

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Please enter a valid phone number.
Patient Email
example@example.com
I authorize Grace Health to (Choose One):*

Send Information TO - another person or Facility (not Grace Health)Obtain Information FROM - another facility (not Grace Health)Personal Use/Self - Please Select Method Below
If Personal Use/Self, select method for Obtaining Personal Records:
Name of Facility / Provider / Person*
Facility Phone Number*
Please enter a valid phone number.
- For faxing records provide the facility fax number.
- For emailing records provide the facility email address.
- For mailing records provide facility address.
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Fax Number
Please enter a valid phone number.
Facility Email
example@example.com
Contact Authorization*

If I do not provide a valid email address, fax number, or mailing address for the facility/person listed above, I authorize Grace Health to contact the facility/person to collect the necessary contact information only for the purpose of sharing my medical records as described in this authorization.
Release of Records Time Frame
I understand that if I do not designate a specific date range, I (or designated recipient) will receive only the last 24 months of records requested.*

Default RangeSpecific Date Range
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
I acknowledge*

I request the following information to be released, which may include but is not limited to history, testing, diagnosis, and/or treatment of drug or alcohol abuse, mental health (such as psychotherapy and behavioral health), communicable diseases and infections (such as venereal disease, Tuberculosis, Hepatitis A, B, C, HIV, HIV testing), Acquired Immunodeficiency Syndrome (AIDS) and AIDS related complex (ARC).
Grace Health's Designated Records Set:
- Photocopy of release request
- Progress notes (24 months)
- Test Results of Labs (24 months)
- Immunization records (pediatric patients only)
- Medication/Allergy Lists
- Growth chart: Birth - 5 years (pediatric patients only)
- Office visit notes (including PCP and any specialties as applicable)
- Radiology
- Diagnostic testing
- Consults (24 months)
- Procedures
- OB Records (current pregnancy only)
- Sensitive Information (if authorized, 24 months)
  
  Note: Information will be provided 24 months in the past from signature date on Authorization for Release of Medical Information.
Specific Information to be Released*

All records in designated record set per Grace Health policyLab ResultsMedical VisitsImmunizationsDental RecordsMental HealthOB/GYNSpecialty VisitsDental X-RaysSubstance Use Disorder (SUB) / Medication Assisted Treatment (MAT)Other
Purpose of Release:

Transferring care to another providerForm completed by Grace Health (FMLA, Health Appraisal, School Forms, etc.)Other
Authorization:*

I give Grace Health the authorization to verbally exchange information with the named facility/person listed above regarding the information being released. I understand there is a possibility the information may be redisclosed by the recipient and no longer protected under the federal privacy rules. I understand this is an optional form and my refusal to sign it will not affect my ability to obtain treatment and I may obtain a photocopy of this form on request. This release is effective for one year from the date of execution. However, it may be revoked by me at any time by providing written notice to the above-named party; I understand information may have been released when authorization was valid. I authorize Grace Health to use and disclose any records protected by 42 CFR Part 2 for treatment, payment, and operations (TPO). Substance Use Disorder (SUD) release authorization is ongoing until revoked by written notice. A facsimile or photocopy of this document will be accepted in lieu of the original. I consent to receive all records and communications electronically.
Signature*

Clear
Name*

First NameLast Name
Signer is:*

Patient / Legal RepresentativeParentGuardian
Date*

MonthDayYear
Date
Should be Empty: