Authorization for 1215 East Michigan Avenue Disclosure of-2026

1. Click ‘Get Form’ to open the Authorization for Disclosure of Protected Health Information in the editor.
2. Begin by entering the patient's full name, birth date, address, and phone number in the designated fields. This information is crucial for identifying the individual whose health information is being disclosed.
3. In section 1, specify the organization authorized to disclose the protected health information (PHI). You can enter 'Sparrow Health System' or another entity as applicable.
4. For section 2, provide details about the person or organization that will receive this information. Include their name, address, email (if known), and phone number.
5. In section 3, select the specific types of information you wish to be disclosed by checking the appropriate boxes. This may include medication lists, immunization records, and more.
6. Complete sections 4 through 11 by indicating the purpose of disclosure and any preferences regarding how you would like to receive your requested information (e.g., paper copy or electronic).
7. Finally, ensure that all signatures are completed at the bottom of the form. If a representative signs on behalf of the patient, additional verification details must be provided.

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