Medical Records Release

Macomb Physicians Group, PLLC — Medical Records Release

Authorization To Use Or Disclose Medical Information
(Healthcare facility/physician) to release the protected health information (PHI) described below. Unless specifically excluded, the PHI may include information about: alcohol and drug abuse treatment, behavioral or mental health services and/or communicable diseases and infections, such as sexually transmitted diseases, AIDS and HIV.
RELEASE TO:

SPECIFIC TYPE OF INFORMATION TO BE RELEASED:

PURPOSE AND NEED OF SUCH DISCLOSURE:

AUTHORIZATION:

I understand that unless revoked, this authorization is valid for 90 days from the date of signing. I may revoke this authorization in writing at any time except to the extent disclosure has already been made in accordance with this document. Once health care information is disclosed, the person or organization that receives it, may re-disclose it, and that it may no longer be protected by privacy laws.