Record Release Form

Record Release Form
Record Release Form
419 W. Wackerly

Midland MI 48640

Main Phone: 989.631.9515

Fax# 989.835.6824
Hugo Juarbe, MD

Jennifer Maxam, DO

Cheri Daniels, PA-C

Brittany Reiber, PA-C

Jamie Kretz, RN, Care Manager
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 NameLast Name
DOB*

MonthDayYear

Electronic Medical Record (EMR) transfer via fax	Zero charge
Paper Chart transfer via fax	$6.50 flat fee
Paper copy of records	$1.45 per page fee for the first 20 pages, $0.72 pages 21-50, $0.29 pages 51+

Please select one*

Entire recordLast 2 years of active careLast 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*

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