Patient Forms

Advance Directives

See Designating a Patient Advocate.

Authorization to Communicate and Leave Telephone Messages

• Authorization to Communicate and Leave Telephone Messages (PDF, 17KB) -
  Use this form to allow us to leave you more detailed messages or to talk to other people about your health.

Medical Records

• Medical Records Release - Learn how to request copies of your medical record.

Nonopioid Directives

These forms enable you to document your wish to avoid receiving opioid medications while in our hospitals.

• MDHHS-5793 Nonopioid Directive (English)(.dotx, downloads from MDHH website)
• MDHHS-5793-AR Nonopioid Directive (Arabic)(.dotx, downloads from MDHH website)
• MDHHS-5793-SP Nonopioid Directive (Spanish)(.dotx, downloads from MDHH website)

Pediatric Forms

• Temporary Delegation of Guardian/Parental Rights and Limited Power of Attorney for Consent to Provide Treatment - This form may be used for a parent/guardian to grant written permission if your child or ward needs non-emergency medical care, whether in a doctor’s office or in the hospital.
• MyMichigan Health School Based Health Center Consent Form - Sign this form and return it to the School-Based Health Center. Student can be seen with or without parent/guardian once this consent is signed.
• Sports physicals (.pdf, downloads from MHSAA website) - This form is required by many school and private sports programs. Complete the student and parent portions of this form and bring it with you to your scheduled sports physical.