Client Information Release Authorization

  • Any personal or medical information obtained about me will be kept confidential. This information will be shared with others for legitimate purposes only. This information will not be shared without my permission.
  • This consent may be revoked at any time, by a signed written statement.
  • I certify that all the information I have provided herein is true. I also understand that I may be asked to show proof of any information I have given.
  • You may also qualify for the new Medicare prescription drug benefit program. If you would like more information, please visit the Medicare website or call 1-800-633-4227.

I hereby authorize Health Plan Management Services to share information with organizations, physicians, clinics and hospitals in order to verify my eligibility and manage my participation. I hereby agree by pressing the Agree button below.

Copyright Ingham County Health Department 2001