| Regarding release
of your health records University Health Service
recognizes and supports patients' rights to confidential medical
care. Our staff are committed to ensuring your confidentiality,
and all staff, both permanent and temporary, sign agreements to
that effect.
If you are 18 years old or older, or an emancipated minor (defined
under Michigan law as being married, emancipated through a court
order, or on active duty in the armed forces prior to age 18), your
health records will be released only with your written consent.
If you are less than 18 years old, UHS is obligated by law to release
health records (except related to sexually transmitted diseases,
contraception and pregnancy testing) to your parents or guardian
if they request them.
Request for entire record may include alcohol and drug abuse/treatment; psychological and social work counseling; HIV
or AIDS or ARC; communicable disease or infection including sexually transmitted diseases, venereal diseases and hepatitis;
and demographic information.
To request a copy of your health
records
In person Picture identification is required when
requesting health records in person. Visit the Health Information
Management Services (basement level of UHS) and complete an "Authorization
for Release of Medical Information."
By mail or fax Print and complete the
Authorization for Release of Health Information
or otherwise send a written request addressed to UHS, including:
- Your full name
- Your date of birth
- Your identification number
- Specific report(s) needed
- To whom the information is to be sent
- Address where information is to be sent
- Reason for request (optional)
- Date by which information is needed (if applicable)
- Date of request
- Your daytime phone number (in case we have questions)
- "I may revoke this authorization except if UHS has already acted on it."
- "This authorization will expire in 60 days."
- Your signature (required)
Send the request to
University Health Service
207 Fletcher St.
Ann Arbor, Michigan 48109-1050
Attn: Correspondence
or fax it to 734-936-3063
When requesting a copy of your health records, please allow at
least 5 days for the record to leave UHS.
For further information, call the UHS Health Information Management
Services at 734-936-3275. |
