Your Child’s Medical Record
The results of all laboratory tests, X-rays, other diagnostic studies, and medical treatment received while hospitalized or treated as an outpatient are documented. Also included are physician reports from examinations, surgery, treatment and medications, and observations by nurses and other members of your health care team. This information is combined to make up your child’s medical record. A signed authorization is necessary to receive a copy of your child’s medical record, or to have it sent to another organization, physician, insurance company, school, etc. You can obtain an authorization form by stopping by any University of Michigan Hospital or Health Center registration desk, if requested. The Registration Desk will fax the completed form to medical records. You can download the authorization form here or call Release of Information at 734-936-5490. 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.
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. Upon completion of the authorization form, you may ask Registration to fax your completed form to U-M Health Information Management at 734-936-8571 or mail to: Health Information Management Release of Information Unit 2901 Hubbard Rd. #2722 Ann Arbor, MI 48109 Routine requests include operative reports, consults, test result reports, and recent discharge summary. You must specify if additional information is requested. There may be a fee for medical record copies. There is no charge for records sent directly to care providers. For legal guardians, please attach a certified copy of legal guardian appointment to the request form. If you have any questions regarding copies of your child’s medical records, please contact the Release of Information Unit at 734-936-5490.
Medical Record Release Forms
Authorization to Release Patient Information from UMHS (PDF) To be used when the patient (or designated individual) is requesting their UMHS health information to be SENT to someone outside the institution. Records will be sent through the U.S. Mail. Records needed for medical emergencies will be faxed directly to a physician or medical facility. Our average turnaround time for processing requests is seven business days. Records requested for reasons other than continuing medical care will be assessed a fee. This includes patients requesting copies for themselves. Fees are outlined on the 2nd page of the Authorization to Release Patient Information from UMHS form (PDF )
Personal Health Record
The PHR is a collection of important information that you maintain about your child’s health. PHRs may be short and simple or very detailed. A PHR can be in the form of:
- paper documents
- electronic files maintained by you on your personal computer
- documents you create using tools available through the internet
Family and Friends List for Outpatient Clinics Only
This form documents my request to allow family members and/or friends to be involved in verbal discussions regarding my health care.
If the Family & Friends List is NOT completed, members of the patient’s health care team may still, subject to their professional judgment, share information that is directly relevant about the patient with the patient’s family members or friends who are involved in the care of the patient and/or payment for healthcare
Certain information requires a special authorization covering sensitive information. This includes psychiatric, drug and/or alcohol abuse, HIV/AIDS, and sexual abuse information. Authorizations for sensitive information must specifically refer to the information that is to be released. Sensitive information is never faxed, per hospital policy and protection of your privacy.
Mott does not provide copies of death certificates. For information about how to obtain a copy of a death certificate, please call the Washtenaw County Clerk’s Office of Records and Deeds at 734- 222-6720.