Lenawee County, MI · Lenawee County
Authorization Form for Release of Health Information
Lenawee County residents use this form to authorize the county health department to obtain or release specified health information.
At a glance
- Issued by
- City of Lenawee County · Lenawee County, Lenawee County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- lenawee.mi.us
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This authorization lets a patient direct the Lenawee County Health Department to obtain health information or release it to a named recipient. It asks for the patient's contact details, the recipient's information, which records may be shared, and the purpose of the authorization. The form also includes an expiration, revocation conditions, and signature lines for the patient or authorized person and a witness.
Who needs it
A patient, or an authorized person such as a parent or guardian, uses this form to authorize the county health department to obtain or release health information.
How to submit it
The form says to fax or send the information to the Lenawee County Health Department at 517-264-0790. The department's address is 1040 S Winter Street, Suite 2328, Adrian, MI 49221.
About notarization
This document is signed without a notary; the patient or authorized person and a witness sign and date it.
How to submit this form
- 1
Download the Form
Download the Lenawee County authorization form for release of health information.
- 2
Complete the Form
Enter the patient's details, recipient information, records to be shared, purpose, and expiration information.
- 3
Sign and Date
The patient or authorized person and a witness sign and date the form.
- 4
Send to the County
Fax or send the information to the Lenawee County Health Department at the address or fax number shown on the form.
Frequently asked questions
- Do I need a notary for the health information release form?
- No. The patient or authorized person and a witness sign and date this form; it does not require notarization.
- How do I submit the health information release form?
- The form says to fax or send the information to the Lenawee County Health Department at 517-264-0790. Its address is 1040 S Winter Street, Suite 2328, Adrian, MI 49221.
- What information can I authorize the department to release?
- The form lists options such as immunization records, test results, and all medical records for a specified period. It also provides an option to identify other information.
- How long does the authorization last?
- The authorization expires one year from the signature date or on another expiration date entered on the form. It may be revoked in writing.