Requesting Your Medical Record

For Copies of you Platinum Anesthesia Medical Record

If you were a patient of the Novi Surgery Center and would like a copy of your Platinum Anesthesia medical records for yourself or to send to another person or company, please send or fax a letter and include the following information:

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1. Patient’s full name

2. Patient’s date of birth

3. Date(s) of service or date range of the medical records you want

4. Purpose of your request (e.g., personal use, physician, attorney, court, etc.)

5. How you would like your medical records sent:

   • by mail, please include the delivery address,

   • by fax, please include the fax number, or

   • by secure email, please clearly write the email address

6. The requesting person’s name, signature, and date

7. The requesting person’s relation to the patient (e.g., self, parent, personal representative)

8. If the personal representative is signing the letter on behalf of the patient, please provide a description of your authority to act on behalf of the patient and a copy of official documentation granting this authority.

For Third Parties
If you are a third party (e.g., attorney’s office, car insurance company, etc.) and are initiating a request for a patient’s Platinum medical records, please send an authorization form or download the Authorization Form (link on this page) and have the patient complete it.

Where to Send Your Request
You may send us your letter or completed Authorization Form in one of the following manners:

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By Mail:
Novi Surgery Center

25500 Meadowbrook Road

Suite 10

Novi, MI 48375

By Fax: 248-522-0090
By Email: pjarbit@gmail.com

PLEASE NOTE: Before using email to communicate your request, you should understand that there are certain risks associated with the use of email. It may not be secure, which means your email could be intercepted and seen by others.

Questions?
If you have questions about your request, please contact Platinum - through the Novi Surgery Center at 248 477-2200.

Please contact the Novi Surgery Center for information regarding fees associated with the release of requested medical records.

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