Patient Forms

Call (954) 319-0592 for Billing or MEDICAL RECORDS REQUESTS.  Leave your name and telephone number.   Your call will be returned as soon as possible with instructions.  A medical records release form is required.

Print and fill out the following forms and mail to 1415 Myrtle Oak Ter, Hollywood, FL 33021 or for email see below.


You may also e-mail completed forms to but e-mail is not considered a secure means of communication. If you chose to e-mail also return "E-MAIL PERMISSION FORM" with the MEDICAL RECORD RELEASE FORM. Type in subject line "MEDICAL RECORDS REQUEST FORMS"   Click on the form below to download. It down loads immediately, so check your download file.  Each form is provided in both pdf and word for your convenience. Which ever works best for you.  


If you have not had an acknowledgement of your request within 3 days please resend it and/or call (954) 319-0592 and leave a message. Records should be sent to within 30 days of receipt of request.   


Adobe Acrobat document [298.1 KB]
Medical Information Release Form.pdf
Adobe Acrobat document [154.5 KB]
Microsoft Word document [19.4 KB]
Medical Information Release Form.docx
Microsoft Word document [24.4 KB]