Forms - Sparrow Health System 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient’s Name, Birth date, and Address in the designated fields. Ensure accuracy as this information is crucial for identification.
3. In section 1, authorize Sparrow Hospital to disclose your protected health information (PHI) by checking the appropriate boxes related to your treatment history.
4. Specify the Person or organization authorized to receive your information in section 2. Include their name, address, email, and phone number for clarity.
5. Detail the Specific Type of information you wish to be disclosed in section 3. Check all relevant boxes and list any specific dates of service.
6. Complete either section 4 or 5 based on your research purpose. Circle 'current' or 'future' as applicable.
7. Indicate whether you agree to condition healthcare services on this authorization in section 6 by checking YES or NO.
8. Sign and date at the bottom of the form. If applicable, ensure a witness signs as well.

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