• 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
    Cheri Daniels, C.P.N.P     989.631.9515
    Ashley Badour, Care Mgr     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:

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    Pick a Date
  • Electronic Medical Record (EMR) transfer via fax                $15.00 flat fee

     

    Paper Chart transfer via fax                                                   $25.00 flat fee

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    Pick a Date
  • *If printed paper copies are requested of a chart we will follow fee schedule of charge per page.

  • Should be Empty: