Release of Medical Records Form

RELEASE OF MEDICAL RECORDS TO THE UNIVERSITY OF MICHIGAN MEDICAL SCHOOL

As an aid in the study of a body, it is desirable to have access to the medical records of the deceased. So that we may obtain a copy of pertinent medical records, we ask that you provide a statement of release to each hospital, doctor, or other health care provider who will have cared for you in the event of major illness or surgery. If the facility or provider does not have a standard release form, use this form:

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Print Donor Name

request that a copy of my medical record at

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Name of Facility

be made available to the Anatomical Donations Program of the University of Michigan Medical School when requested.

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Signature

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Date

ANATOMICAL DONATIONS PROGRAM
Office of Medical Education
University of Michigan Medical School