Structure
The Michigan MC 315 form plays a crucial role in the legal landscape by facilitating the release of medical information during court proceedings. This form is specifically designed for cases involving probate matters, where the health status of an individual may be a significant factor. It allows patients to authorize healthcare providers—such as doctors or hospitals—to share their medical records with specified parties involved in a lawsuit. The form outlines key details, including the patient’s name, date of birth, and the specific medical information being requested. Importantly, it ensures that the custodian of these records must make the information available for inspection or provide a certified copy to the requesting party. The authorization is valid for 60 days, which emphasizes the time-sensitive nature of legal proceedings. Furthermore, the form includes essential warnings about the potential redisclosure of sensitive health information, reminding patients of their rights to revoke the authorization if needed. Understanding the MC 315 form is vital for anyone navigating the complexities of legal cases that involve medical information, ensuring that all parties can access the necessary documentation while respecting patient privacy and rights.
Form Example
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Original - Records custodian |
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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
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Probate In the matter of |
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1. |
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Patient’s name |
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Date of birth |
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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. |
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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 |
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Case No. |
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CERTIFICATE |
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I am the custodian of medical information for |
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Organization |
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I received the attached authorization for release of medical information on |
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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 |
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Name (type or print) |
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Address |
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City, state, zip |
Telephone no. |
Document Specs
| Fact Name | Description |
|---|---|
| Purpose | The Michigan MC 315 form is used to authorize the release of medical information, ensuring that relevant health records are shared during legal proceedings. |
| Governing Law | This form is governed by Michigan Compiled Laws (MCL) 333.5131(5)(d) and the Michigan Court Rules (MCR) 2.506(l)(1)(b). |
| Validity Period | The authorization granted by this form is valid for 60 days, allowing for timely access to medical information during ongoing legal matters. |
| Patient Rights | Patients have the right to revoke the authorization at any time, as long as no actions have been taken based on the authorization prior to revocation. |
| Confidentiality Risks | By signing the form, patients acknowledge that there is a risk of their protected health information being redisclosed by the recipient. |
| Record Custodian | The form requires the name and address of the medical records custodian, ensuring that the correct entity is contacted for information release. |
| Information Scope | The medical information authorized for release may include sensitive records related to mental health, substance abuse, and communicable diseases. |
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