Record Release Form

Record Release Form
Record Release Form
419 W. Wackerly

Midland MI 48640

Main Phone: 989.631.9515

Fax# 835.6824
Hugo Juarbe, M.D.     989.839.8804

Jennifer Grossman, D.O.     989.374.0142

Brittany Reiber, P.A.-C     989.631.9515

Jenna Lyons, C.P.N.P     989.631.9515
TAX ID# is 38-2156008
MICHIGAN MEDICAL RECORDS ACT provides that physicians may charge for copies of medical records (see details below).

It is important to emphasize the MEDICAL RECORDS ACT should be interpreted in conjunction with the FEDERAL HIPAA PRIVACY REGULATIONS. HIPPAA further provides that practices should charge reasonable, cost-based fees.

Our policy was updated March 15, 2022 to reflect the following charges:
Detail of Medical Records charges for this patient:
Patient Name: *

First Name Last Name
DOB *

Month Day Year
Electronic Medical Record (EMR) transfer via fax $15.00 flat fee

Paper Chart transfer via fax $25.00 flat fee
Please select one *

Entire record Last 2 years of active care Last 1 year of active care
I authorize Family Medicine Associates of Midland to release the following medical information to:
(Please list above name of provider and fax number where records are to be sent)
Signature *
Date *

Month Day Year
Please contact the office to make payment arrangements so that records release can be processed. Contact Kim at (989) 374-0131 *

Agree
*If printed paper copies are requested of a chart we will follow fee schedule of charge per page.
Should be Empty: