Authorization to Disclose/Release Protected Designated Health Record Set Information
Please complete this form in its entirety so we can help you receive the information you are requesting.
1.	This authorization is voluntary. I understand that Community First Health Centers will not base treatment, payment, enrollment, or eligibility for beneﬁts on my signing this document.
Patient Full Name: 	Maiden/AKA: 	Date of Birth:	 Street Address: 			 
City/State/Zip: 	Telephone #:	

Email Address: 	

2.	[ ] Myself: I request Community First Health Centers to release my protected health information to Myself.
Select delivery method: [ ] Email [ ] Pick up in office [ ] US Mail (to address listed above)  [ ] Fax:	
3.	[ ] Other: I am the patient, or legal authorized representative of the patient listed above and request Community First Health Centers to release my protected health information(or the patient information listed above)to:

Individual/Person: 	Company/Organization: 			 Street Address: 			 City/State/Zip: 		Telephone #: 		
Fax #:	
Select delivery method: [  ] Fax  [ ] US Mail [ ] E-mail	

4.	Purpose of release/disclosure to other person/organization:
Reason for Disclosure
[  ] Continuation/Transfer of Care
[  ] Attorney/Legal
[  ] Insurance Company
[  ] Workman’s Compensation 
[  ] Patient Directive
[  ] Other (specify):	

5.	Records to be released:
I hereby authorize Community First Health Centers to release/receive any and all medical records and information as speciﬁed below, relating to my care and treatment which may include x-rays, photographs, electronic and digital ﬁles and any other records, unless I expressly direct or specify otherwise. I understand that medical information may include records if any, relating to treatment for alcohol and drug abuse protected under the regulations in 42 C.F.R. Part 2; psychiatric/ psychological services and social work records, and any information regarding communicable diseases and infections, deﬁned by Michigan Department of Public Health rule, which can include tuberculosis venereal diseases, sexually transmitted diseases, acquire immunodeﬁciency syndrome (AIDS), human immunodeﬁciency virus (HIV) or AIDS-Related Complex (ARC). This does not include psychotherapy notes.

Information to be released (be speciﬁc):

[ ] Only medical records (The Designated Record Set) from date(s) of service listed:	  [ ] X-Ray Results (Specify date(s): 	 [ ] Lab Results (Specify date(s): 	  [ ] Other Records or Information (Specify):		  [ ] Entire Medical Record (The Designated Record Set) :	 
[  ] Minor Consented Services in accordance with Michigan Law
Check below for any EXCLUSION:
[ ] Alcohol/Substance Abuse [ ] Mental Health Records [ ] HIV/AIDS
[ ] Other (specify):	

6. Release of records TO Community First Health Centers:

[ ] I authorize release of records to Community First Health Center 
       ATTN: Medical Records, 1011 Military Street, Port Huron, MI, 48060 
         Fax # 810-488-8005 

[ ] I authorize release of records to Community First Health Centers 
       ATTN: Medical Records, 555 St. Clair River Drive, Algonac, MI, 48001 
         Fax # 810-794-7645 

[  ] I authorize release of records to Community First Health Centers
ATTN: Medical Records, 58144 Gratiot Avenue, P.O. Box 480430, New Haven, MI. 48048 
Fax # 586-749-5560 

[  ] I authorize release of records to Community First Health Centers 
ATTN: Child and Adolescent Health Center School-Based Health Program, 5200 Taft Road, Algonac, MI 48001
Medical/Primary Care:  Fax # 810-777-9971  

[  ] I authorize release of records to Community First Health Centers 
ATTN: Teen Health Center, 2215 Court Street. Port Huron, MI 48060.
Medical/Primary Care:  Fax # 810-987-1651     

From:
Name:	

Street Address and City/State/Zip: 			 

Telephone #: 	 Fax #: 	

Oﬃce Use Only

Send Medical Records Via:

[ ] US Mail  [ ] Fax	[ ] Email

7.	I may revoke this authorization in writing by sending a written notice to the Community First Health Centers location where you received services addressed to the attention of Medical Records. A request to revoke an authorization would not affect any actions already taken by Community First Health Centers based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. I may inspect or copy (at additional expense) the information to be used or disclosed, as provided in CFR 164.524. This authorization expires upon my revocation of this consent or within one calendar year of being signed. If you wish to have this authorization expire before one calendar year, please indicate the date of expiration here: _________	.

8.	To protect your health record information, any information requested to be sent by email will be encrypted and password protected unless it is requested otherwise. Communications sent by email over the Internet are not always secure and may be intercepted and read/ received by someone other than who it was addressed to. Choosing to have the requested health information by email implies that you accept this risk.

   Patient or legally authorized individual Signature	                          Print Name	                                             Date	            Time
   *If this authorization includes records related to minor-consented services, the minor patient must sign this authorization when required by
applicable law.
    [ ] Translation Provided
 	
Witness signature	Date

The Standards for Privacy of Personally Identiﬁable Health Information, 45 CFR Parts 160 and 164, states that information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient of this information. The federal conﬁdentiality Rules CFR Part 2 prohibit making any further disclosure of drug or alcohol information unless further disclosure if this information is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 1.
	                                                                                            11/14/2018

 June 2026

This institution is an equal opportunity provider.
Partially funded by a Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health, and Human Services Grant