Original - Records custodian 2nd copy - Requesting party 1st copy - Court 3rd copy - Patient Approved, SCAO JIS CODE: AFR STATE OF MICHIGAN CASE NO. JUDICIAL DISTRICT AUTHORIZATION FOR RELEASE JUDICIAL CIRCUIT COUNTY PROBATE OF MEDICAL INFORMATION Court address Court telephone no.Plaintiff Defendant v Probate In the matter of AUTHORIZATION 1. Patients name Social security no. Date of birth 2. I authorize Name and address of doctor, hospital, or other custodian of medical information to release Description of medical information to be released (include dates where appropriate) to Name and address of party to whom the information is to be given 3. I understand that unless I expressly direct otherwise: a) the custodian will make the medical information reasonably available for inspection and copying, or b) the custodian will deliver to the requesting party the original information or a true and exact copy of the original information accompanied by the certificate on the reverse side of this authorization. I understand that medical information may include records, if any, on alcohol and drug abuse, psychology, social work, and information about HIV, AIDS, ARC, and any other communicable disease. 4. This authorization is made in accordance with Michigan Court Rules and is valid for :six months after being signed. will expire on . upon . Date happening of a specific event This authorization is signed to make medical information regarding me available to the other party(ies) to the lawsuit listed above for their use in any stage of the lawsuit. The medical information covered by this release is relevant because my mental or physical condition is in controversy in the lawsuit. 5. I understand that by signing this authorization there is potential for protected health information to be redisclosed by the recipient.6. I understand that I may revoke this authorization, except to the extent action has already been taken in reliance upon this authorization, at any time by sending a written revocation to the doctor, hospital, or other custodian of medical information. Date Signature Address Name (type or print) (If signing as Personal Representative, please stateCity, state, zip Telephone no.under what authority you are acting) 45 CFR 164.508, MCL 333.5131(5)(d),MC 315 (10/03) AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION MCR 2.506(I)(1)(b), MCR 2.314<<<<<<<<<********>>>>>>>>>>>>> 2 CERTIFICATE 1. I am the custodian of medical information for . Organization 2. I received the attached authorization for release of medical information on . Date 3. I have examined the original medical information regarding this patient and have attached a true and complete copy of the the information that was described in the authorization. 4. This certificate is made in accordance with Michigan Court Rule. I declare that the statements above are true to the best of my information, knowledge, and belief. Date Signature Name (type or print) Address City, state, zip Telephone no.