Authorization For Clinical Communication - University of Michigan 2025

1. Click ‘Get Form’ to open the Authorization For Clinical Communication in the editor.
2. Begin by filling in your personal details: enter your name, birthdate, and medical record number (MRN) in the designated fields.
3. Indicate whether you are the patient or a legally authorized representative. Provide the name of the healthcare provider from whom you are requesting communication.
4. Specify the individuals or organizations with whom clinical information will be shared. Ensure that all relevant parties are listed accurately.
5. Detail the specific information needed and the date range for which this information is requested. Check all applicable boxes for types of information to be released.
6. State the purpose of this release by selecting from provided options or specifying another reason if necessary.
7. Set an expiration date for this authorization, noting that if left blank, it will expire six months from the signature date.
8. Finally, sign and date the form at the bottom, ensuring that all required fields are completed before submission.

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