• Room B390, 1011 N. University Ave, Ann Arbor, MI 48109-1078
• General Information:  734-647-1937
• For record duplication only:  734-764-6152
• Fax: 734-615-7040

The following forms can be printed and completed by you prior to your appointment to bring with you.

• Registration Form
• Health History Form
• Consent Form

If you would like a copy of your records, we require a release form and a small processing fee.  You will need to download the form below (2 pages).   Print, complete and return with payment by fax, mail or in person to Central Records.

• Authorization to Release Patient Information

• Friends and Family Form

• HIPAA information
• U-M Notice of Privacy Practices
• Patient Rights and Responsibilities