Southern Michigan Pain Consultants
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Patient Forms

The following forms are available online for your convenience. If you have any questions please feel free to contact us.

Need to Request a Copy of Medical Records from SMPC?

To obtain records, submit a signed and dated Authorization for Use or Disclosure of Protected Health Information to the clinic.  The form may be obtained at the clinic, or through this link:

After you complete and submit the form to the clinic, it is reviewed by the clinic staff and put in your file. Your request is processed by BACTES Imaging Solutions, our HIPAA Business Associate.

Some requests are processed at no charge to the requesting party (such as referrals for continuing care).  Other requests are charged a fee, in accordance with state statutes. BACTES bills requesting entities such as attorneys, insurance companies, etc. directly; patients are not billed for this work.

Patients who request records for their personal use or for transferring to another pain clinic, or similar provider, will be charged a fee.  This explained in the fee for records letter available at the clinic or at above link.

BACTES processes the requests and delivers an invoice detailing the fee for the requested records.  Upon receipt of payment, BACTES delivers a copy of the records to the requestor.

Please allow 7 business days after your forms have been accepted by SMPC for processing and delivery of the invoice.

After 7 business days, patients with questions on the status of their request should call the BACTES center for personal medical records requests (248) 977-3926.

After 7 business days, attorneys, insurance companies, etc. with questions on the status of their request should call the BACTES center for third party medical records requests (800) 560-3800.

Need to Send a Copy of Medical Records TO SMPC?

New and returning patients often need to have certain medical records sent to SMPC to assist in their diagnosis and treatment.  If you need your current (or previous) provider to send your records to SMPC, a request form may be obtained at the clinic, or through this link:

Do you need help with where the info should be sent? Please check with SMPC clinic staff to obtain the mailing address for where your records should be mailed.

Pain Resources

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Portage Office
3770 Glenkerry Ct
Portage, MI 49024
(269) 329-2887

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