Medical Records - How to Request

Paroled/Discharged Prisoners:
In order to obtain a copy of a prisoner’s medical file a written request must be submitted. The written request must include the former prisoner’s name, address, prison number, signature and the medical records that are being requested. The Michigan Department of Corrections’ (MDOC) Patient Authorization for Disclosure of Health Information (CHJ-121) authorization form should be used for this request. To receive a copy of the CHJ-121 authorization form please call 517-780-5936, 517-780-5929 or 517-780-
5673 . If the requestor is a guardian or power of attorney for the former prisoner, please include a copy of the relevant document(s) indicating such authorization.

Requests should be submitted to:

Duane Waters Health Center
Attention: Health Information Services
3857 Cooper St., Jackson, MI 49201
Fax to 517-780-5724 or fax number 517-780-5405
E-mailed to clarkcl@michigan.gov

Once the request is received, a pre-payment fee will be mailed to you.

The fee breakdown is as follows (fees subject to the Medical Record Access Act):
$23.42 initial fee
$1.17 per page for the first 20 pages
$.59 cents per page for the next 21 – 50 pages
$.23 cents per page for anything over 51 pages

Postage is charged when mailing a package. This is determined by the amount of pages mailed.

**We recommend that requests for copies of health records for Disability Claims be requested by the agency and not by the former prisoner.

Agencies for Continuance of Care Regarding Paroled/Discharged Prisoners:
The requesting agency’s authorization can be used if it contains the language releasing communicable diseases. Otherwise, the Michigan Department of Corrections’ (MDOC) Patient Authorization for Disclosure of Health Information (CHJ-121) authorization form should be used. The patient’s signature must be dated within 59 days of our receipt. The patient’s signature for Federal and State Government agencies can be dated within 12 months of our receipt. If the patient has a guardian or power of attorney, the relevant document(s) indicating such authorization must be included with the request.

Attorneys and Insurance Agencies Regarding Paroled/Discharged Prisoners:
The requesting agency’s authorization can be used if it contains the language releasing communicable diseases. Otherwise, the Michigan Department of Corrections’ (MDOC) Patient Authorization for Disclosure of Health Information (CHJ-121) authorization form should be used. An authentic photocopy of the authorization is valid. Subpoenas are valid if they are signed by the court. If the patient has a guardian or power of attorney, the relevant document(s) indicating such authorization must be included with the request. There is a pre-payment fee unless you provide two pieces of identification proving medical indigency (i.e., bridge card along with a valid driver’s license, health care card or identification card.) Fee breakdown is the same as for paroled/discharged prisoners.

Prosecuting Attorneys Regarding Paroled/Discharged Prisoners:
The requesting agency’s authorization can be used if it contains the language releasing communicable diseases. Otherwise, the Michigan Department of Corrections’ (MDOC) Patient Authorization for Disclosure of Health Information (CHJ-121) authorization form should be used. The client’s signature must be dated within 59 days of our receipt. An authentic photocopy of the authorization is valid. Subpoenas are valid if they are signed by the court. If the patient has a guardian or power of attorney, the relevant document(s) indicating such authorization must be included with the request. Fees will not be assessed for documents requested by Prosecuting Attorneys as they are appointed by the court.

Agencies Requesting Medical/Dental Records/Dental Films for Identification Purposes:

A written request on the requesting agency’s letterhead must be submitted to:

Duane Waters Health Center
3857 Cooper Street Jackson, MI 49201
Fax (517) 780-5724

Obtaining Medical Records for Incarcerated Prisoners:
Medical records are kept at the prisoner’s locking facility and must be requested from the Health Information Manager of that facility. The Michigan Department of Corrections’ (MDOC) Patient Authorization for Disclosure of Health Information (CHJ-121) authorization form should be used for this request. The request must include the medical records being requested. Please call the Health Information Manager of the prisoner’s locking facility to receive a copy of this form. The authorization can be sent by mail, fax or email. Fee breakdown is the same as for paroled/discharged prisoners. If the requestor is a guardian or power of attorney for the prisoner, please include a copy of the relevant document(s) indicating such authorization.



Related Documents
CHJ-121 Medical Release Form 06-17 PDF icon