Medical Records Authorization (HIPAA) - Michigan

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — MICHIGAN

This Authorization is executed in connection with a personal-injury matter so that the Patient and/or the Patient's attorney may obtain the Patient's medical records.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following health-care provider(s), facility(ies), clinic(s), pharmacy(ies), laboratory(ies), insurer(s), or custodian(s) of records to release the Protected Health Information ("PHI") described below:

3. RECIPIENT(S) — PERSON(S) AUTHORIZED TO RECEIVE RECORDS

4. RECORDS AUTHORIZED FOR RELEASE

Date range of records: [__/__/____] to [__/__/____] (or ☐ all dates).

Check each category of records to be released:

• ☐ Complete medical record / designated record set
• ☐ History and physical examination reports
• ☐ Office/progress/treatment notes
• ☐ Hospital and emergency department records
• ☐ Operative and surgical reports
• ☐ Physician orders
• ☐ Laboratory and pathology reports
• ☐ Radiology/imaging reports and films (X-ray, MRI, CT, mammogram, ultrasound)
• ☐ Physical therapy / rehabilitation records
• ☐ Prescription and pharmacy/medication records
• ☐ Billing statements, itemized charges, and payment records
• ☐ Diagnostic test results
• ☐ Discharge summaries
• ☐ Other (specify): [________________________________]

5. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

The following categories are protected by heightened confidentiality rules. Initials document the Patient’s request but do not replace a standalone authorization or consent when governing law requires one. In particular, psychotherapy notes and Part 2 records must not be released solely on these initials; attach a compliant standalone document.

HIV-specific authorization (MCL § 333.5131): I understand that all reports, records, and data associated with HIV infection and AIDS are confidential, and that a written authorization to disclose my own HIV-related records must contain a specific statement specific to HIV infection or AIDS. By initialing above, I provide that specific written authorization to release HIV/AIDS information to the Recipient(s) named in Section 3 for the purpose stated in Section 6.

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

6. PURPOSE OF DISCLOSURE

The purpose of this disclosure is:

• ☐ Legal representation / evaluation, prosecution, or settlement of the Patient's personal-injury claim
• ☐ At the request of the Patient
• ☐ Other (specify): [________________________________]

7. HIPAA REQUIRED STATEMENTS

7.1 Expiration. This Authorization expires on [__/__/____], or upon the following event: [________________________________]. If no date or event is specified, this Authorization expires upon final resolution of the Patient's personal-injury claim or three (3) years from the date of signature, whichever occurs first.

7.2 Right to Revoke. I understand that I may revoke this Authorization at any time by delivering written notice to the provider/custodian identified in Section 2. Revocation will not apply to information already released in reliance on this Authorization before the provider receives my written revocation. (45 C.F.R. § 164.508(c)(2)(i).)

7.3 No Conditioning of Treatment. I understand that the provider may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

7.4 Redisclosure Notice. I understand that information disclosed under this Authorization may be redisclosed by the Recipient and may then no longer be protected by HIPAA. (Special-category records under Section 5 remain subject to the redisclosure prohibitions of 42 C.F.R. Part 2 and applicable Michigan law.)

7.5 Right to a Copy. I understand that I am entitled to a copy of this signed Authorization.

7.6 Voluntary. I understand that signing this Authorization is voluntary.

8. MICHIGAN COPY-FEE AND RESPONSE-TIME NOTE

Under the Michigan Medical Records Access Act, MCL § 333.26265 (access) and § 333.26269 (fees), a health care provider, health facility, or medical records company must provide copies on the patient's or authorized representative's request. The permissible fees (CY 2026, adjusted annually by MDHHS for the Detroit CPI) are:

• Initial fee: $32.08 per request (a patient is not charged the initial fee for the patient's own medical record);
• Per page: $1.60 for the first 20 pages, $0.80 for pages 21–50, and $0.32 for pages 51 and over;
• Postage/shipping: actual cost; and
• Retrieval: actual cost of retrieving records 7 years old or older not maintained or accessible on-site.

All fees must be waived for a medically indigent individual (limited to one set of copies per provider). For patient-directed requests, HIPAA cost-based fee limits under 45 C.F.R. § 164.524 also apply.

Under the HIPAA right of access (45 C.F.R. § 164.524), a covered entity must generally act on a request within 30 days (with one 30-day extension on notice).

9. SIGNATURE

Personal Representative (if Patient is a minor, incapacitated, or deceased)

Notary (optional)

State of Michigan, County of [________________________].

Subscribed and sworn to before me on [__/__/____] by [________________________________].

Sources and References

• HIPAA authorization core elements — 45 C.F.R. § 164.508: https://www.law.cornell.edu/cfr/text/45/164.508
• HIPAA right of access — 45 C.F.R. § 164.524: https://www.law.cornell.edu/cfr/text/45/164.524
• Substance use disorder records — 42 C.F.R. Part 2: https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2
• Michigan Medical Records Access Act, MCL § 333.26269 (fees): https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-333-26269
• 2026 Medical Records Access Act Fees (MDHHS): https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder2/Folder2/Medical_Records_Access_Act_Fees.pdf
• MCL § 330.1748 (mental health record confidentiality): https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-330-1748
• MCL § 333.5131 (HIV/AIDS confidentiality): https://codes.findlaw.com/mi/chapter-333-health/mi-comp-laws-333-5131/