Request Medical Records

Step 1 of 2 – Patient Information

Patient Name*
DOB

MM

DD

YYYY
Address*

Street Address

City

State

ZIP Code
Phone Number*
Email

Practice | Hospital | Office*
Attention To
Phone Number*
Fax Number
Email
Address

Street Address

City

State

ZIP Code
Information to be released
Select all that apply
Records
Comments | Notes
Release Instructions
Release Method
Date (needed)

Please allow 7-10 days for processing
Purpose of Release
Purpose of Release Comments

Download our Medical Records Request Form with a click.

Free call 24/7
1-888-409-8006

9325 Glades Rd. # 205 Boca Raton, FL 33434
983 N. University Dr. Coral Springs, FL 33071
280 SW Natura Ave Deerfield Beach, FL 33441

1-888-409-8006

Our Partners Relations Center is meant to provide all our partners, with information, tools and resources with the end goal of benefiting both their patients and themselves.

Every time we get a referral, we contact the patient to confirm the appointment for the initial consultation. After communication with the patient is establishes, a member of our Physician Relations Team will contact you with updates.

Useful Links

Locations

9325 Glades Rd. Suite 295 Boca Raton, FL 33434
983 N University Dr. Coral Springs, FL 33071
280 SW Natura Ave. Deerfield Beach, FL 33441

MEDICAL RECORDS REQUEST

Step 1 of 2 – Patient Information

Information to be released

Release Instructions

DOWNLOAD FORM

EMERGENCY CONTACT

LOCATIONS

PATIENT SUPPORT

Useful Links

Locations

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