Request Medical Records

Obtaining Copies of Your Medical Records
Release of Information (ROI)

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
  • Hospital registration number (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

Authorization to Release Copies of a Medical Record - Spanish Version

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.

Health Information Management(HIM)
M-F 8 a.m. - 5 p.m.
Release of Information(ROI)Unit
2901 Hubbard Rd #2722
Ann Arbor, Michigan 48109-2435
Phone: (734) 936-5490
Fax: (734)936-8571