PROTECTED HEALTH INFORMATION ACCESS FORM
You may use this form to authorize family members, friends, or other third‑party individuals or organizations to access your Protected Health Information (PHI) from Copper Ridge Surgery Center. By completing this form, you grant the listed individual(s) or entity permission to access your PHI and to contact us to discuss or request that information. The access form remains valid for one year, unless you specify a shorter time period. Completed forms may be submitted to Copper Ridge Surgery Center using any of the following methods.
Email:
Note: Using this email link will transmit information from your personal email address to medicalrecords@surgerytc.com Email sent from your personal email address may not be secure. Please be aware of this risk when sending Protected Health Information (PHI) covered under the Health Insurance Portability and Accountability Act (HIPAA) in this manner.
Fax:
231-392-8973
Mail:
Copper Ridge Surgery Center
Attn: Medical Records
4100 Park Forest Drive
Traverse City, MI 49684