• Adult Consent Form

  • Adult Consent 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

  • This form is to allow us to release test results or other health information directly relevant to your ongoing care to whomever you authorize.  This is not a release of medical records.  This information will be used in the event that you are not available to receive your test results or other care information and would like that information given to a designated person; for example, your parent, aunt, grandparent.  THIS IS NOT A MEDICAL RELEASE FORM.

    This authorization is valid for one year, unless updated and initialed by the patient.

    Test results may be released to the following:

  •  - -
    Pick a Date
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