Forms for PHI from a Hospital or Healthcare Provider

Ascension Borgess - Authorization to Release Health Information

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Ascension Crittenton Hospital - Authorization to Release PHI

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Ascension Michigan - Authorization to Release PHI

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Ascension Michigan - Authorization to Release PHI - Genesys HS - SJHS - Crittenton

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Beaumont Authorization for Release of Health Information

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Bronson Health - Authorization to Release PHI

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Cleveland Clinic - Authorization to Release PHI

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CMS Medicare - Authorization to Disclose Health Information

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Detroit Medical Center - Authorization to Release PHI

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Garden City Hospital - Authorization for Use or Disclosure of Health Information

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Garden City Hospital - Authorization to Release PHI

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Great Lakes Bay Health Centers - Authorization to Release PHI

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Harbor Oaks Hospital - Authorization to Release PHI

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Henry Ford Health System - Authorization to Release Medical Information

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Hillsdale Hospital - Authorization to Release PHI

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Holland Hospital - Authorization to Release Medical Information

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Hope Network - Authorization for Disclosure of Information

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Kettering Health Network - Authorization for Disclosure of PHI

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Kettering Physician Network - Authorization for Disclosure of PHI

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Life EMS - Authorization for Use and Disclosure of PHI

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Memorial Healthcare - Owosso - Authorization to Release PHI

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Mercy Health - Grand Rapids - Authorization to Release PHI

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Mercy Health - Toledo - Authorization to Release PHI

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Mercy Health - Saint Joseph - Authorization to Release PHI

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Metro Health Hospital - Authorization for Release of Health Information

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Michigan Head & Spine - Premier MRI - Pure HealthyBack - Authorization for the Use and Disclosure of Individually Identifiable Health Information

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Michigan Medicine - U of M - Authorization to Release Medical Records

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Mid-Michigan Health - Authorization to Release PHI

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Molina Healthcare - Authorization to Release PHI

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Molina Healthcare - First Recovery Group - Authorization to Release PHI

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Michigan State University HealthTeam - Authorization to Release PHI

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ProMedica - Authorization to Release PHI

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Scheurer Hospital - Authorization to Release PHI

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Sparrow - Authorization to Release PHI

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Spectrum Health - Authorization to Release PHI

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St. Mary Mercy Hospital - Authorization for Use and Disclosure of Health Information

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St. Mary's of Michigan - Authorization to Release PHI

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University of Wisconsin - Authorization to Release PHI

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UP Health System - Marquette - Authorization to Release PHI

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Priority Health- Authorization to Release PHI

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Munson Healthcare - Authorization to Release PHI

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IINN - Authorization to Release PHI

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Hurley Medical Center - Authorization to Release Medical Information

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CIGNA - Authorization for Disclosure of Information

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