Dch 1183-2025

1. Click ‘Get Form’ to open the dch 1183 in the editor.
2. Begin by entering the individual's name, ID number, and contact information in the designated fields. Ensure accuracy for proper identification.
3. In the section labeled 'I AUTHORIZE THE MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES (MDHHS) TO SHARE MY HEALTH INFORMATION', specify the type of health information you wish to share. You can choose to share all information or list specific types.
4. Provide details about the person or organization that will receive this information, including their name, address, and phone number.
5. Indicate the reason for sharing your health information in the appropriate field. This could be for discussing healthcare benefits or other relevant purposes.
6. Review the authorization statements carefully before signing. Make sure you understand your rights regarding this authorization.
7. Finally, sign and date the form at the bottom. If applicable, include your relationship to the individual if you are a legal representative.

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