Release of Protected Health Information

LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS

HEALTH DEPARTMENT

1260 AJIJAAK AVE

PETOSKEY, MI 49770

P: 231-242-1700

LITTLE TRAVERSE BAY BANDS HEALTH DEPARTMENT

RELEASE OF PROTECTED HEALTH INFORMATION

I understand that I have the right to request restrictions as to how my protected health
information may be used or disclosed to carry out treatment, payment, or healthcare
operations, or other disclosures. I also have the right to authorize the release of my
protected health information to members of my family, friends, and/or any person
that is involved in my care.

I authorize the following person(s) to obtain my health information:

Signature of patient or legal representative (if legal representative, state relationship to patient):

clear

Expiration date of authorization:

Date:

Witness name and signature:

clear