Hiv Details

Are you one of those people who dreads filling out hospital discharge forms? If so, you're not alone. These documents can be confusing and time-consuming to complete. However, with the right tools, you can make the process a little easier. The Hospital Discharge Forms Download from provides everything you need to get your paperwork handled quickly and easily. This downloadable package includes all the forms you'll need to leave the hospital, including a release form for your doctor, a post-hospital care plan, and more. Plus, our helpful guide will walk you through each step of the process so that you can minimize any hassle or stress.

Listed below are some specifics of hospital discharge forms download. This figure can provide details about the form's size, finalization time, and the areas you're needed to fill.

Form NameHospital Discharge Forms Download
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

Faxed to number below






Questions: Contact Medical Records: 313.916.4540

Please mail completed form to: Medical Records 2799 W. Grand Blvd., Detroit, MI 48202 or to Medical Records

email address: • fax number 313.916.3917 (Please keep in mind that emails sent over the internet may not be secure.)

Patient Information (please print)

Name (First, Middle, Last)



Maiden name or previous names






Zip Code

Date of Birth



E-mail Address if Applicable


I authorize my records to be sent from:

Henry Ford Health System:

HF Allegiance Health

HF Macomb Hospital

HF Allegiance Specialty Hospital

HF Maplegrove Center

HF Behavioral Health

HF West Bloomfield Hospital

HF Hospital Detroit

HF Wyandotte Hospital

HF Kingswood Hospital

HF Other (Clinic/Medical Center): __________________

Other Facility:





Zip Code





I authorize my records to be released to:

Myself: (Select only one option)

MyChart patient portal

E-mail to me at address above

Mailed to me at address above


(patient request)



On site inspection. (Authorization is valid only if received by Henry Ford Health System within 60 days of the date signed.)

Mailed to address below

Verbal communication about my care. Describe information to be shared: ____________________________


Other: Disclose to - complete information below





Zip Code

Phone Number


Fax Number


Form #: 26091 Rev. 01.21

Page 1 of 2


Please complete below if you want to include medical records for these services:

Substance Use Disorder diagnosis and treatment


Continuation of Care



Other ______________

Psychotherapy Notes

Specific Information Requested:

Type of Record requested

Date of Service

Discharge Summary

Emergency Department

Laboratory Report


Inpatient Record

Type of Record Requested

Date of Service

Outpatient Record

Radiology Report

Office Note



By signing this authorization I hereby authorize Henry Ford Health System to disclose information contained in the medical record of the patient identified above, which includes information that may be stored in a paper and/or electronic format, as set forth below. Such notes may contain information on: general medical care, psychological and social work counseling; human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) or AIDS related complex (ARC), as applicable; communicable diseases or infections, including sexually transmitted diseases, venereal diseases, tuberculosis and hepatitis, as applicable; demographic information; and treatment received by other health care providers. Any alcohol and substance use disorder information disclosed to you in these records is protected by Federal confidentiality rules (42 CFR Part 2). 42 CFR Part 2 prohibits unauthorized disclosure of these records. Patient access fee may apply for copies. Fees are authorized annually by the State of Michigan Medical Records Access Act, P.A. 47 of 2004, MCL 333.26269.

I understand that:

I may revoke (take back) this authorization at any time. Revocations to this authorization must be presented in writing. Revocation will not apply to the information that has already been released prior to receiving the revocation. Contact Henry Ford Health System Medical Records department. Contact information is available at the top of the form.

This authorization expires when the patient information is disclosed as permitted in this authorization, or within one

(1) year from the date that it is signed unless another expiration date is written here: ____________________________

_______________________ (describe the date/event/condition upon which authorization will expire, which must be no longer than one year from the date signed)

My care or treatment will not be conditioned on signing this authorization

The person(s) to whom information is disclosed under this authorization may possibly redisclose the information to others without the patient’s knowledge or consent and therefore the privacy of personal and health information may no longer be protected by law.

Henry Ford Health System and/or its copying service reserve the right to charge for processing and copying information. This fee is waived when releasing information directly to a treating physician or health care facility.

Signature _____________________________________________ Relationship (if other than patient) ______________

Patient, Parent of Minor, Legal Guardian, Personal Representative, Heir at Law, Person under a POA. (if legal guardian, Personal Presentative or person of authority under a durable medical power of attorney, a copy of appropriate documentation may be required)

Date________________________________________ Time_______________________________

Form #: 26091 Rev. 01.21

Page 2 of 2


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