Form MC 315 at a glance
What it is: Form MC 315 is the Authorization for Release of Medical Information.
Who signs: The patient signs on the Signature line; if signing as Personal Representative, please state under what authority you are acting.
The authorization is valid for 60 days and is signed to make medical information regarding you available to the other party(ies) to the lawsuit listed, for their use in any stage of the lawsuit. The medical information covered by this release is relevant because your mental or physical condition is in controversy in the lawsuit.
A filled-in Form MC 315 example: a plaintiff authorizes a hospital to release records
How to fill out Form MC 315, box by box
Court, Plaintiff, Defendant, Probate and In the matter of
Fill in the JUDICIAL DISTRICT, JUDICIAL CIRCUIT or COUNTY, then the Court address and Court telephone no.
Enter the Plaintiff and the Defendant.
If the matter is Probate, mark Probate and enter In the matter of.
Patient's name and Date of birth
Enter the Patient's name and Date of birth.
2. I authorize, to release, to
After I authorize, enter the Name and address of doctor, hospital, or other custodian of medical information.
After to release, enter the Description of medical information to be released (include dates where appropriate).
After to, enter the Name and address of party to whom the information is to be given.
I understand that unless I expressly direct otherwise
Unless you expressly direct otherwise, the custodian will make the medical information reasonably available for inspection and copying, or will deliver to the requesting party the original information or a true and exact copy accompanied by the CERTIFICATE.
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.
By signing this authorization, you understand there is potential for protected health information to be redisclosed by the recipient.
You may revoke this authorization at any time by sending a written revocation to the doctor, hospital, or other custodian of medical information, except to the extent action has already been taken in reliance upon this authorization.
Date, Signature and Name
Enter the Date.
Enter the Name (type or print); if signing as Personal Representative, please state under what authority you are acting.
Enter the Address, City, state, zip and Telephone no.
CERTIFICATE
In the CERTIFICATE, the custodian of medical information enters the Organization it is the custodian for and the Date it received the attached authorization for release of medical information.
The custodian has examined the original medical information regarding this patient and has attached a true and complete copy of the information that was described in the authorization.
The custodian declares that the statements are true to the best of its information, knowledge, and belief, then enters the Date, signs on the Signature line, and enters the Name (type or print), Address, City, state, zip and Telephone no.
More rules for Form MC 315
Original for the Records custodian, 1st copy for the Requesting party, 2nd copy for the Patient.
Sources
[1] Form MC 315 (6/17), Authorization for Release of Medical Information, Michigan State Court Administrative Office (the Official source link on this page).