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Medical Record Request

 

BE KIND TO MOTHER NATURE, WE PREFER TO RECEIVED AND SEND ELECTRONIC RECORDS VIA OUR EMAIL OR OUR ELECTRONIC FAX

 

Please read carefully and choose the correct form for your request.

Upon completion, you may chose to mail, email, or fax the form to us. 

Your request will be process within 2-5 business days.

For urgent request, please give us a call at 727-391-4100. 

 

RECORD TO US

This form is your authorization for our practice to request your medical records. 

Click to view or download form

 

All records can be send and received via mail, email or fax. 

 

RECORD FROM US

This form is your authorization for our practice to send your medical records to a destination of your choice. Fee might apply for request of paper copies and/or certified mail. 

Click to view or download form

 

All records can be send and received via mail, email or fax. 

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