(1) Failure to complete this form may result in a denial of your request.
(2) For contract or RFP/RFQ, please identify contract number or RFP/RFQ number and a description.
(3) If the requested record pertains to an individual other than the requestor, a notarized authorization to release the record may be required from the person who is the subject of the request.
(4) If the request is too broad, depending on the description of your request, we may deny your request or request that you submit a deposit payment, prior to searching for the requested record.
(5) Medical record requests (e.g., EMS run sheets or billings) must comply with HIPAA and the Michigan Medical Records Access Act.
(6) I acknowledge that if this request is made within 30 days of a motor vehicle accident report being filed, I am prohibited from doing the following: using the report for any direct solicitation of an individual, vehicle owner, or property owner listed in the report, or disclosing any personal information contained in the report with a third party for commercial solicitation of an individual, vehicle owner, or property owner listed in the report until 30 days after the date the report is filed.
(7) This form is for DPD RECORDS ONLY.
Click checkbox below to acknowledge and accept the Note above.