I. My Authorization

I authorize Michigan Employment & Training Plus (MET PLUS)
to use or disclose the following health information.

 My health information relating to today’s treatment & visit.

II. My Rights I understand that I have the right to revoke this authorization.
I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my permission cannot be taken back.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

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If the patient is a minor or unable to sign Please Disregard the remaining sections of this form and, please email Met Plus for Further Instructions. Contact@MetPlus.org