Hearing and/or Vision Record Request

Use this form to request hearing and/or vision screening records from the Midland County Department of Public Health (MCDPH) for individuals that were screened in Midland County, MI.

Record requests will be reviewed during normal clinic hours (Monday-Friday 8am-5pm), and we will contact you to gather additional record release information.

If you are experiencing a medical emergency, call 911 or proceed to the nearest emergency room.

This form is secure and HIPAA-compliant. Please provide as much detail as possible.

1. Who are you requesting records for? *This question is required.

First Name:
Last Name:
Date of Birth (MM/DD/YYYY):

2. Requestor information: *This question is required.

First Name:
Last Name:
Relationship to person you are seeking records for:

3. What type of record are you requesting? (check all that apply) *This question is required.

Hearing
Vision

4. If no record is located, would you like to be contacted to schedule a screening appointment? We schedule hearing and vision screening for individuals age 3-18 years of age. *This question is required.

Please enter an 'other' value for this selection.

5. Have you signed up for our Patient Portal? *This question is required.