Naples Vascular Specialists

Available Forms

Portal Medical Records Release Portal New Patient Registration Portal New Patient Registration Financial Policy Portal New Patient Registration Financial Policy and Assignment of Benefits Portal New Patient Registration Privacy Policy

Portal Medical Records Release

Medical Records Release AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS Naples Vascular Specialists 130 9th St N, #120 Naples, FL 34102 pone 239-649-0550 fax 239-649-1785

Where Records Are Located

Name, Address, Phone/Fax of where your records that you want sent to Naples Vascular Specialists are currently located.

Patient Name and Date of Birth

Enter your full name and date of birth

I hereby authorize the release of any and all of my medical records (including any and all HIV/AIDS records, alcohol and/or substance abuse records, and psychiatric and/or psychotherapeutic records.)

Information to be released to: James M. Scanlon, M.D. Naples Vascular Specialists 130 9th Street N, Suite 120 Naples FL 34102 Phone (239) 649-0550 Fax (239) 649-1785

Purpose of Disclosure

I request that copies of my medical record be made and mailed or delivered in a timely manner to the above address. I do hereby agree to hold Naples Vascular Specialists, its agents and staff members free and harmless from any actions by it or them for alleged invasion of privacy, liable or slander, or defamation, arising in connection with the disclosures of such information.

Patient or Guardian Signature and Date *

Type Name and Date

Witness Signature and Date *

Type Name and Date

* Required field