Medical Associates of West Florida, LLP

7575 State Road 52
Bayonet Point, FL 34667

Telephone: (727) 861-9800

Fax: (727) 245-1390

Authorization to Use or Disclose Protected Health Information

Request for Medical Records

I, (name of patient):authorize:

JUDITH NOEL, MD

JOHN PIRRELLO, MD

MARIO TALANGA, DO

NARENDRA PATEL, MD

KRISHNA RAVI, MD

DANIEL TERRONE, DO

SONAL PATEL, MD

NAVIN YADLAPALLI, MD

To: Release Medical Records to

Or: Request Medical Records From

Provider's Name

Address

City

State

Zip Code

Phone Number

Fax Number

PLEASE SEND THE MOST RECENT ONE YEAR HISTORY

If more than 25 pages, please mail do not fax.

The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information where indicated).

Progress Notes

X-Ray and Diagnostic Testing

Pathology

Fees for Medical Records

Fees for copying records for patient’s personal use are one (1) dollar per page for the first 25 pages and .25 (25 cents) for each additional page thereafter. (Rule 64B8-10.003 of the Florida Administrative Code)

I hereby agree with the terms provided in this Request for Medical Records form.
Patient Initial

Patient Signature

Date

Patient or Authorized Person:

Parent

Legal Guardian

Executor