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Embed code for: 16.10-19 fax t Zucker
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October 19, 2016
Plastic Surgery Center, P.C.
621 Memorial Dr., Ste. 511
South Bend, IN 46601
Re: Crystal Simpson
Our File #33875.5
Dear Madam or Sir:
Enclosed is an Authorization to Disclose Patient Health Information executed by Crystal Simpson. This authorization complies with the requirements of HIPAA and CFR 164.508. The request for the release of these medical records is specifically being made by the patient. Crystal Simpson requests that you provide this information to Conybeare Law Office, P.C. Please provide the information requested in paragraph 3 of the authorization.
As you are probably aware, HIPAA requires that the records requested be provided within 30 days of the request and that any fees charged only reflect the actual and reasonable cost to you of reproducing these records for the patient. We appreciate your cooperation in providing these records for the benefit of your patient. Please submit any bill for payment to our firm.
Also be advised that this is a Michigan no-fault claim. All bills should be submitted to, with a copy of your office note, the no-fault insurance carrier: Akiiki L. Davidson, AAA, Franklin Facility, 25510 W. 11 Mile Rd., Southfield, MI 48034-2261, phone: 248-226-7460, fax: 844-309-8531, claim #400616978. Crystal Simpson is not responsible for any bills. If you have any questions or need any additional information, please do not hesitate to contact me or Gayle Chacon, the legal assistant assigned to the file.
CONYBEARE LAW OFFICE, P.C.