Michigan Form Mc 315 PDF Details

In Michigan, navigating the complexities of legal proceedings involves a meticulous approach to managing sensitive information, particularly when it comes to medical records. The Michigan MC 315 form plays a pivotal role in this process, outlining a structured procedure for the authorization and release of medical information in the context of legal disputes. This form serves as a crucial link between healthcare providers, patients, and the judicial system, ensuring that medical details relevant to a case are shared in a controlled and lawful manner. It is primarily utilized when the medical condition of an individual is directly relevant to the legal matters at hand, for instance, in personal injury cases or disputes where physical or mental health is in question. The form requires detailed information, including the patient's consent and understanding of what their authorization entails, such as the potential for redisclosure of their health information. With sections dedicated to the custodian of records, the party requesting this sensitive information, and a detailed description of the information being requested, the MC 315 form also emphasizes the patient's rights. This includes their ability to revoke the authorization and the conditions under which the information must be handled. Designed to protect patients' privacy while facilitating the fair use of medical records in legal settings, this authorization form reflects the balance between the right to privacy and the requirements of justice.

QuestionAnswer
Form NameMichigan Form Mc 315
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmichigan release form, michigan authorization medical form, michigan mc release information form, michigan 315 information online

Form Preview Example

 

Original - Records custodian

 

1st copy - Requesting party

Approved, SCAO

2nd copy - Patient

STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE

AUTHORIZATION FOR RELEASE

OF MEDICAL INFORMATION

CASE NO.

Court address

Court telephone no.

Plaintiff

Defendant

 

 

 

v

 

 

 

 

 

 

 

 

Probate In the matter of

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

Patient’s name

 

 

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 valid for 60 days and 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

Name (type or print) (If signing as Personal Representative, please state under what authority you are acting)

Address

City, state, zip

Telephone no.

 

45 CFR 164.508, MCL 333.5131(5)(d),

MC 315 (6/17) AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

MCR 2.506(l)(1)(b), MCR 2.314

Authorization for Release of Medical Information (6/17) Page

 

of

 

 

 

Case No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 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.

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Step number 1 of filling in michigan authorization release information

2. Right after finishing this section, head on to the subsequent step and fill out the essential particulars in these fields - Name and address of party to whom, I understand that unless I, a the custodian will make the, information accompanied by the, I understand that medical, and information about HIV AIDS ARC, This authorization is valid for, is relevant because my mental or, I understand that by signing this, recipient, I understand that I may revoke, and Date.

This authorization is valid for, information accompanied by the, and and information about HIV AIDS ARC inside michigan authorization release information

3. The following segment is about Signature, Name type or print If signing as, Address, City state zip Telephone no, AUTHORIZATION FOR RELEASE OF, and CFR MCL d MCR lb MCR - fill in these empty form fields.

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4. It's time to begin working on this fourth segment! Here you've got these Authorization for Release of, Page, CERTIFICATE, Case No, I am the custodian of medical, Organization, I received the attached, Date, I have examined the original, information that was described in, This certificate is made in, I declare that the statements, Date, Signature, and Name type or print fields to fill in.

michigan authorization release information writing process detailed (portion 4)

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