Medical Records

City *

Zip Code *

Patient Last Name *

HIV/AIDS DISCLOSURE: I consent to the release of any positive or negative test results for AIDS or HIV infection., antibodies to AIDS, or other infections with any causative agent of AIDS with the rest of my medical record *

Yes

Patient Service Desk

Medical Records

Medical record procedures are regulated by the (HIPAA) Notice of Privacy Practices Act. Your records are completely confidential.

Due to HIPAA regulations, your medical information can be released only after your written authorization is received.

You can fill out the on-line form below or print the preferred form and return to us.

To Obtain Medical Records from a previous Physician or Facility

To Release Medical Records from Generations OB-GYN

To inquire with any question or concerns to the medical records department, please contact or call (248) 647-9860 extension 1237.

Choose from the following options to return the forms:

Mail: Generations OB-GYN

Attention: MEDICAL RECORDS

35046 Woodward Ave Ste 100

Birmingham MI 48009-0932

Fax: (248) 633-2110

Email: records@securemyobgyn.biz

SUBMIT MEDICAL RECORDS RELEASE AUTHORIZATION FORM

Records from healthcare providers other than Generations OB-GYN will not be disclosed.

Requested By Date *

Patient First Name *

Contact State/Province *

Street Address *

Contact Phone *

Enter Named Patient OR Physician Contact *

Contact City *

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Obstetrics

Gynecology

Doctor-On-Call Calendar

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Intra-Office

(248) 647-9860

Information to be released *

Contact Zip Code *

Contact Street Address *

State/Province *

Home Phone *

Country *

Cell Phone *

Type your name in the box. This acts as an electronic signature. I understand that according to the rules set by the Michigan State Board of Medical Examiners, Generations OB-GYN has 15 business days from the date this form was received to provide me with an exact copy of the above requested information within my medical record. I am also aware that a fee may apply for this request and is SOLELY my responsibility. *

Patient Previous Name(s)

35046 Woodward Ave Ste 100

Birmingham MI 48009-0932

f (248) 647-9864

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Contact Fax *

Purpose of disclosure *

If other, be specific

I understand this acts as written authorization for Generations OB-GYN to release medical information to the Named Patient OR Physician *

Yes

Date of Birth *

If other, please be specific

Patient Service Desk ​

Medical Records​

Meet Our Practice

Obstetrics

Gynecology

Doctor-On-Call Calendar

Education and Awareness

Spa

Intra-Office

Patient Service Desk

Medical Records