Request Medical Records

Records can be released to anyone that the patient authorizes (in writing). A valid authorization MUST contain the following information or the request will be returned:

• Patient's full name and date of birth (list any other names the patient may have had
• Medical Registration Number (MRN) (if available)
• Specific information being requested (e.g., type of report/information and dates of service, etc.)
• Purpose for which the information may be disclosed
• To whom the information is to be sent (name and address)
• Specify authorization's expiration date if desired (see ROI form)
• The patient's signature or a patient's legal representative's signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
• Date of the signature.

Authorization to Release Copies of a Medical Record - CHINESE

Authorization to Release Copies of a Medical Record - JAPANESE

Authorization to Release Copies of a Medical Record - ARABIC

Requests for Medical Records of Deceased Patients

Requests for medical records of deceased patients require a letter of authority in addition to your signed request. The letter of authority is given to the executor of a person's estate by the Probate Court upon their death. Releasing records to anyone other than the executor is illegal, as stated in Michigan Court Law 600.2157. Please also include your phone number in case we need to contact you for additional information concerning your request.

Third-Party Requests for ePHI

Michigan Medicine is able to provide third parties with direct access to our EMR through technologies such as the EpicCare Link Provider Portal. Requests will be reviewed on an individual basis. A valid reason for a request should be established (such as requests from a payor for payment purposes). A valid Business Associate Agreement (BAA) and/or and authorization to release from the relevant patient(s) may be required. Please contact the Health Information Exchange Support Help Desk for more information at 734-615-0872 - Option 2.

Contact Information

Revenue Cycle Mid Service (HIM)
Release of Information (ROI) Unit
3621 S. Street 700 KMS Place
Bay 11 – Mid Service
Ann Arbor, Michigan 48108-1633
Phone: (734) 936-5490
Fax: (734) 936-8571