916 Myrtle Avenue • Sturgis, MI 49091-2391
MR# _______________________
ACCOUNT# _______________________


Patient Name: Date of Birth:
Phone Number:    

I hereby Authorize Sturgis Hospital to use or disclose my protected health information indicated below to:

Name of Person and/or Agency
Street Address
City: State: Zip:
Phone Number: Fax Number:

Specific Type of Information and Date(s) of Treatment to be Disclosed; please check all boxes that apply:
Discharge Summary   ER reports
History & Physical Exam   LAB reports
Operative reports   Radiology reports
Consult reports   Other:

Purpose and Need for Such Disclosure
Personal Use Continuing Care Insurance Attorney/Legal Other
I wish my request to be FAXED. I do not wish my request to be FAXED.
I hereby consent to the release and/or review of any medical information which may include the following: records of alcohol, drug abuse, psychiatric illness, and any other information regarding communicable disease and serious communicable diseases which includes venereal diseases, Tuberculosis, Hepatitis B, HIV infection, Acquired Immunodeficiency Syndrome (AIDS), or Acquired Immunodeficiency Syndrome Complex (ARC).
I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
I understand that this authorization may be revoked by me at any time by notifying Health Information Management, in writing, of my desire. I understand that revocation of this authorization will not affect any information already released. I understand the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
This authorization shall expire without express revocation 90 days (3 months) from the date written below OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me: