Authorization to disclose protected health ... - State of Michigan - michigan 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and address in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the CSHCS/Medicaid ID number, city, state, ZIP code, and county. This helps streamline processing with the Michigan Department of Community Health.
4. Provide the parent or guardian's name and contact details. If their address differs from the patient’s, include that information as well.
5. In the authorization section, specify the name and complete address of the specialty doctor, hospital, or clinic authorized to release medical information.
6. Review all entries for completeness and accuracy before signing. The signature must be from either the patient or a legal guardian.
7. Finally, ensure you retain a copy for your records and send the appropriate copies to the designated parties as instructed.

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