Michigan HIPAA Authorization Template (Word + PDF)

The one-page form that lets your family actually talk to your doctors.

Providers can refuse to discuss your care with anyone you have not authorized in writing. This stand-alone HIPAA authorization is built around the federal core elements in 45 C.F.R. § 164.508 with Michigan medical-records overlays, so the people you name can receive your information — before incapacity, or even if they are not your patient advocate.

What’s included

• HIPAA Authorization template naming multiple authorized people
• Scope, purpose, and expiration options
• Revocation statement
• Optional witness and notary lines (practice only)

Signing requirements in Michigan

No witnesses or notary are required. Sign and date; give copies to your providers and the people you name.

Format and delivery

Fillable Word (.docx) template plus a print-ready PDF for the same document, delivered as an instant download after checkout. Every file includes plain-English completion instructions, a signing checklist, and a “common mistakes” list. Version 1.1 — legal research verified September 15, 2026.

Save with a kit

Included in the Michigan Essential Estate Documents Kit and the Healthcare Documents Trio.

Rexford Mercantile is not a law firm, and Jonathan and Ruth Rexford are not attorneys. This is a self-help legal template with general instructions — not legal advice, and no attorney–client relationship is created. You are responsible for confirming the form fits your situation and for signing, witnessing, and notarizing it as your state requires. Consult a licensed attorney in your state if your situation involves a blended family, a beneficiary with a disability, out-of-state property, a business, or a family dispute. Digital download with a 30-day satisfaction guarantee — see our Refund Policy. © 2026 Rexford Mercantile. Licensed for the purchaser’s personal use only; not for resale or redistribution.