--- title: PHI from Insurance Provider description: Michigan Legal Copy Forms for the release of protected health information from an insurance provider. --- [![Michigan-legal-copy-logo_1](https://www.mlcopy.com/hs-fs/hubfs/Logo/Michigan-legal-copy-logo_1.png?width=442&name=Michigan-legal-copy-logo_1.png "Michigan-legal-copy-logo_1")](https://www.mlcopy.com/) [![Start A Record Request](https://no-cache.hubspot.com/cta/default/5105050/1a0d2a84-abf5-49b5-b8be-cb8c32e27c31.png)](https://cta-redirect.hubspot.com/cta/redirect/5105050/1a0d2a84-abf5-49b5-b8be-cb8c32e27c31) ![](https://www.mlcopy.com/hs-fs/hubfs/System%20Icons/menu-logo.png?width=135&name=menu-logo.png) # Forms for PHI from an Insurance Provider ** ### Aetna Authorization to Release PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597022224.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKMuKMe4TUXuO2pvHgpbY2TOmW9cgwR3qmJc4g%2FFbCBt0E588A9%2Bh6L1dBbwmkgJKotcA8rbXET7VqbfJA2ig5XW0Ku9iXyGpZmux2eOw41WQSNEmlWF9da7nkqoJWORwouGeSgBymonRWYYlZIuuxQhhZHbh3L49XNn%2BWQCaWgCOt%2FmBZIBEqkeOuu3Vn2vQGe%2BT89HIgXjEj7U1OeOaNuS7JQ2ni6oxpyWlCqBPxA1QeQgFyaIN4%3D&webInteractiveContentId=196597022224&portalId=5105050) ** ### Anthem- Blue Cross Authorization to Release Records to 3rd Party Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502535.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLUaOI60EXUQX0f%2B2x46VMCFPI13rzDsvR264h6VBpRRaR8A1kic5YyCFL2ZGpYOF3yNK4M8qcbXmKwRiKOWed6LSSHtabTK%2F%2BzjGHF0Ng41waOLLKQD6%2F5EXGOv3rijpFF6TVDMwLz7EBFOf5HlwEZUt5eUhO6%2FKW1R1TwNKsk%2FPj2yAltoy7cVMpoDzIDrofpWaHXnYZoQNTOma%2BS%2BYPfFs8QXMrR0qV%2F9q5BCNorEhICUnAEf6E%3D&webInteractiveContentId=196597502535&portalId=5105050) ** ### BCBS of Illinois- Authorization to Release PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502540.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLICKvG3Ysh%2Bq9xDMaH73jFJEq%2F6jJB%2B9grwb56ZvITee1NznYUa%2BGaCcId%2FiczH5ah8m%2Bx2IPequVV8%2BM2EaCPsLdxBTSEfAC3gGg77IfT0pguEKWIeEh%2FvC6t9yDDxOwdsiHLvyYpCRxdBKlg4bv4msLg6JMwlLdupQwKHtM7QLMu5zgBZBzBrffGr3R%2BBrFvKn1aEQNxdE3cTpYdFTrOBft6fYi7SjsVx3vwrQWgmHuZOzEHrqOk%3D&webInteractiveContentId=196597502540&portalId=5105050) ** ### BCBS of Minnesota- Authorization to Release PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597022239.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLK4EJakr%2B9DlMnWTYIG5eybH8XubSiDBlTuGipol14gp%2BrRH2wtY3oYaMc6Y7D9%2B%2BLXmd1orps2JGQ1BxXHJXuPWLDfVaeWxvXhs%2B34AoEtrRZw2o6oMcIA%2Fi74COeSSjWy%2BhnmVPujg0CVfyMunAGWA%2FqUCG%2FrUbfDK7E6mrEFeZH%2B4Cws%2BU9k%2Bw8SfSRkw36p2GDl0OdA1Ai6eDuaL6iGcvoNqKe1oRz4MG7GEBoJPvriwpg9xvw%3D&webInteractiveContentId=196597022239&portalId=5105050) ** ### BCBS- Blue Care Network of MI- Member Consent for Release of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502546.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLIJWuiORAo68wmtaY1PO%2B0zgTWAU8lb2NC1w2yX01Rjsi2AP88r3Y5soUv766StPigvda17smdCf5ZbQa0B0FwXqCTrITaAprie1TyIkhx22ixvYsBCmYjHuzEyALbOTJeQEoh08IUY0KEElSm8x6KkWTOZbLo3j%2F8U713ZNd1kYPzp0PGyJiNyeiedmlC%2FLiYHdjxYwryiDhhj7a91vUW8y%2FZCo3ncF5HlYnaQY42wRerjRbY9INA%3D&webInteractiveContentId=196597502546&portalId=5105050) ** ### Cigna Healthcare Authorization for Disclosure of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597022255.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLJuIiMBFAj6mRmChrWAZZeSg4mK1LwRezxPFSpKnTKy1G9zxlW6R8Tpe7F6vSHyvHBc1WM1Fxd%2FoxKHZj3egKSKrmcUz4R7CYLqhkmplrH2KQluZ1e%2Bi962Z5shKlyKHFSa48KTp0aSEqP6rvFqBCKulZZGYDGcONZ51%2BspKzzzkMVVNb1qFXYWAWb8g0HdowHJ%2FVDvEeUgkNiJAFsRWSCYTh3xsCBW33UY6eyxglUOvXRC4bFGS80%3D&webInteractiveContentId=196597022255&portalId=5105050) ** ### CMS Authorization to Release Health Information- Medicare- Form Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502560.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKeS6avzN%2BNz%2FvR0dvmFvZlfa6%2FdX1vAZRg4dndAvknYnhhIVK3dNMlCLBTsT%2BpMu5hYuSdCnv3u2lUP5y2XMB1iHXqO9tM2kCc9IixKBo8VHkshkGv2dU3pPUBvJVgrvPuGB0Puzq%2BhrX8S0GKBPVgUsA7IvfPTqlKpzCXz%2FFU%2BxUMtpujnaGwUUXWNil3dy5oID22BEmjGFX67BCtwplBI%2FuaRVRk7vHmsy%2FYEsjwnMNjE0uHsDk%3D&webInteractiveContentId=196597502560&portalId=5105050) ** ### Employee Health Insurance Management- EHIM- Authorization to Release PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502567.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLK%2FeCM9T6T4%2Bwv3m45QoYAcTItPengD0oV8t2liu8uZ0cmgZOgtHStAVhORqW6jiBS%2B%2BHPXwTtdK2AWf3VUL%2F1xx9K%2FFycY4POf77dlwJ%2Bec%2BSOF6oADAhymp82aackETR6hpyv%2Bb7Iv9rc2fZnj89D8RRxrXtdRTTh3x5Jv9q1F35bGY1zL6EN%2FNHpzJspOKD6QnvpMkeHNwP4gzhII9glcLORgH51lteR2zGg2eTyHl3UNoIkFIc%3D&webInteractiveContentId=196597502567&portalId=5105050) ** ### General Insurance Authorization Form Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502572.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLfk2AJVOMuAr2F5FC5gubAxp3kYDLwmX5Uz21T2SGvRMSDlfsxROzigtYolPDLq7LYQO6MrVXJd%2FTm4riH22RvOoKLKvunhOrj28j2vsLWPP9ISoks8w3%2FlFWDKkYpCOp2h26TbUq8U%2Fdw2hs5VAcptY4LQPALMjYZkR2Mz3O1jHj3Ry%2Fbnfejyz5n77ETX0hy4cXCz2h%2B4XbsUEEnJzK4Ct9khLG0YlQLdjCr9sh6s%2BweoitWySJvLnz%2BAxLbZq2iODZOsa3PlLTjAAwY9UjSnzN%2BNvGkE9NBepjTsNiakgfEYTr4eJCe&webInteractiveContentId=196597502572&portalId=5105050) ** ### General Insurance-PIP Authorization Form Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597022286.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKIqahBSMVE5lZIdbE9GHQwu8Hmx9uNFfgSNdtIgJPTOAdwxrOI2hjDYra7nnSpRMbiBLQjtNSI225hyzM8SFKJ0imtMJ%2FsNPtg7fc5vxSnMtG7MVKCxNjzslWFsS97785WdP%2F1veWA7IbjTYYonfV%2BmbLe%2BaqZ6dlF%2Biaf4gWzetUcjyDrClyA2gup385xUbdrKWc5Rqtj6maxe13SmROKbvZTngD7l4vkrNbzezYO9bBymwzBoiFhcQKKQ1FDeDBO3Elp07Ei1mt0dD11PUta%2FpbFB09kTPeOdynBC675oUXC5M2u1imS&webInteractiveContentId=196597022286&portalId=5105050) ** ### HAP- Health Alliance Plan Authorization to Release Health Information Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597022300.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLK%2BMdEOQDjnYcdWNMJzDI8mBn8B04TozyOgVaVKx1JOlIRj1Yd5jusNIOuKnDTQxpNTNTjkS69pKhRVp4nX6auyHuizg9GDjL8MUbOROSLesQgCQGrxsd7LEpZh60W6tXSOuDuPLjTTVxV2y7QIShLW49%2BcYHUky8GjbpwLe3i7ixEpXPGuj2tevLytFEHNll1fxIZHRZcd%2BoguiqNrDncQRHp4Uqx07pxCFsqPWdMkHp%2BxIySFK2Q%3D&webInteractiveContentId=196597022300&portalId=5105050) ** ### Humana- Authorization for Release of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502577.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLIqKvhymULAi8%2FOpswxMO4xk%2BiT5GrFwXe1J7Dmz4jZcY7oG1anW5nhh9MvyVHyDOt5OhbZ0Gde7mgQLLLfGdCFKVsKcq%2F%2FZ0EYzhVen0pu8A145tiU3haojHFK9FxqwVcYDWSnX759kw3%2F8Fs8k%2FMYKXrc4UA9arXZBeqG%2Bkb6sVEqdH%2BjujW9vw2kUu46%2FOxWUImbnMJVtFYjQcs80HK%2B8TzobZGJFAjQqXhge2h6QJLHEhaLw08%3D&webInteractiveContentId=196597502577&portalId=5105050) ** ### McLaren Health Plan- Authorization for Use & Disclosure of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669106.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLmvU%2F%2BqTedU%2FVi2nWCXljLmeBHCUImVybcRWU1tP5BPoWYqTS8DCv%2FcHpiv8rdt1uWzP9g3Huh2g7pzndiy5%2Fo9O63Mjf0HT3sGLGoFyXx4mrL1fGsUy7%2FhoWHYYkmHLbLxkqgXOWw7ryNmVJhUu%2FPY0OU%2BijOHAKFwmNvaS%2FNp0hek0Sa5B5k2piF%2BMpIjQRMTAeAhRsxy8wLRrG8o0fJAVeaKnNc7qcVd5o%2FPnJMQZYx3Cbm98o%3D&webInteractiveContentId=196599669106&portalId=5105050) ** ### Meridian Health Plan- Medicaid HIPAA Authorization to Disclose PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502590.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLZ%2FtQZH4BIYwrMB9CfyO1RcsI7GjSVwFN8IBGe7gpysGMeHPoJ4qY877HCvi79dM2Nb04vTnBtu%2B%2BQfuEXddTmwKdrz%2FCDomneFP77TvCV9T88mB%2FWcZ8B7DojBIArLbP0VRnjv1%2BcYfZhjElUbbrnyQAtU%2BWdXtO6crz3GHkHF2ut1iKkeg%2BTP5DbrekvPL7bMLHhzKeVTA76YmKxsIE2eG1mwaP9c0M1ESCpqt5neLJbu5SA7W4%3D&webInteractiveContentId=196597502590&portalId=5105050) ** ### MESSA Authorization to Disclose PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669125.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKJF37DkNWRaJFSZU3k16B1S4GPBFg973WAxf%2FXYRjgD90jttaOKRy9%2BGvjaPwVer5wqWbl08ESvadCJgLBVqc15DQR1rX0%2Fb6fhT6V8iLqyx%2BrY4AgLvimz%2BDA1EUsASwWmNC8bNiUhG4ZS2EovKOz2CRlC7mzfFJAiApK2OnkxqeNOjRT8Vz%2Fti8Jt1CAod2ppoc15E1w0G%2BBxvgyAPOssFyx4Jp4JBTuvzmBGr%2F4GrHQF9cu2eI%3D&webInteractiveContentId=196599669125&portalId=5105050) ** ### Molina Healthcare Authorization for Use & Disclosure of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196597502607.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLKAGIAH8jP%2F1ZQfwDAct3UgzCEUI3HZ3KKVA%2FGUtEX8VJwW0e1SJC8y1OKp1RwO4TU%2FrbZulVETyBTaxv5tIYkbBE%2Bo0NrjNgME3w%2F0QFkK6JTniPy3o5M%2FQZdBC0if5tqy0atER5vdAge2IY1DPCOKDTxF9OVpjEpIr9egMHbsNENWGjGCpBoD3xBB4Kl5kNoIlFyXRcPHXS7PVtZrnat1y%2BVpn5DmRHfYFjXigVKsjUVIoj2Mc%2B4%3D&webInteractiveContentId=196597502607&portalId=5105050) ** ### Optum- Healthcare Authorization for Release of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669145.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLJc8m15L3fFOarjXPQbqmVgqbseZDKouoQ3tDi9kIcMSvxK33CVnBnE8B7MyC4UBOdEt0uqVjpHidvcnK15k%2FPY%2FkPaRqeXSU2eJiDzY6E%2FAx%2BFr%2BV%2BKYZ5vraBavVAWdS%2F8h6tnbPJmPkpcnr3umKjhzUAKcozI8rGgktGPkk5wXmin9WSOFw1bU%2FDDt2SQ3TmJZjoR3Re0ywVZAzidm9B5pz9fY%2FXjY1Qxp%2Fpg362KKeLApDSiQs%3D&webInteractiveContentId=196599669145&portalId=5105050) ** ### Physicians Health Plan- Authorization for Use-Disclosure of PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669157.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLL%2BMxS6lULgqR%2FEOyK20kxyE60l%2Bm1mgCOC1awM4DYwcy4i58yVFV41foKNr9gl0ZMrHZB3%2BZJS4INX3MiEVzYcZtbzahG9F2YDD9rEOZgScLIdch%2FrgnTjE%2FV%2BuxB9YYE46G3t95oyhPLmxfr2ApGH4BVIjYS0p%2BafJX1NqymKqNg8NYBIjai7yt8vQD96LXenhAPiMEjhHUuU9eFGR9zsVto%2BzBCl%2FGxLxz54b2jzXZK%2BsEGBW08%3D&webInteractiveContentId=196599669157&portalId=5105050) ** ### Priority Health- Authorization for Release PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669168.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLIFs9SRBDClWh0wZ3B58CdNoBxl04H2RkpU%2FrHwJsOfnshTmsitrj%2FOMKJmk8eso3ft5NBlkubBbC2hfNr9TKujq3L0vlKItp7tFSyObIsexOg%2FqHwYRdbkajQvNFqT%2B0mf5B9H2aVdq2z0JWEexdJK%2F8FshXhyUMar8IU3aQ4u8sFEhG5sPLIqCi1vBb73Ya5E%2FVUqA1CPc7GjGosK25JSZlOAVjol6oJbYJ9RfdRXQwNWW8OaP0s%3D&webInteractiveContentId=196599669168&portalId=5105050) ** ### State of MI- MDHHS Authorization to Release PHI- Medicaid & MDHHS Records Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669176.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLI9tCnNmdZbiEkE8E8eaKnec5EpIhrlAvB0PEP5lhGLiBayXfScFDfScp%2Fff8Y9w6HEU81fCkmFlj1G%2BcE0mBToCZZjVJYphpz8OSfPAjSt42eQgz372JVi6MYEW1CtEp29eqMDDP4igB3DXxR8xGsKk44keWO2kiP94DRkFksuUHD0cprnBUDa7OR1zqB6ytqFU6eUHl1enKD9kXilNthOtwYCwVQ%2BTyKgVUXjLxX2uUOfcXOAACngq2AgPCJciinC5BzF%2FdbPtrKtzq834e2%2FN%2F92LC%2BMsVEo8q%2B7LugGcQJTgjgLRHapejPW1j%2FvAvMH0Im6VFw16pqkSUCo1CRJ%2Bg2hgiccTfEt660K&webInteractiveContentId=196599669176&portalId=5105050) ** ### United Healthcare- Authorization to Release PHI Click the button below to access the form [![View Form](https://no-cache.hubspot.com/cta/default/5105050/interactive-196599669261.png) ](https://www.mlcopy.com/hs/cta/wi/redirect?encryptedPayload=AVxigLJTcqz2bphVp7aUD9pVKATp0w0TAsQGVDCXU844aOwde2ETz7ZyNzVz03JYAqEwM2dww35mZuGdCGe57IdKQ6LX3C1ezqY1FvW4l11M7WybrUV4EVPcJPx0CKQjFbao%2BsNV6gIz2RXbh5dDO8%2B3GdcILbo0rUvddFLdkebduLK1a1iHumnkyQlVj5u0P6KwOLXVAJxKU0PV79pO%2BV7YWmcST1H2N%2FHBRjSDlgRCJqkKZddFHFjA6A%3D%3D&webInteractiveContentId=196599669261&portalId=5105050) ## Start Your Record Request Today! 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