Medical Records Release

1
Please use this webpage to request records for the following entities:

Evolve Health

Modern Foot & Ankle

All Podiatry Group

Moore Foot and Ankle Specialists

Spring Branch Podiatry

Florida Orthopedic Foot & Ankle Center

Loretta Henderson, DPM

Adamov Podiatry
2
Are you requesting your own records? [¿Está solicitando sus propios registros?]* This field is required.
Yes (I'm the patient) [Sí (soy el paciente)]
No (I'm not the patient) [No (no soy el paciente)]
3
What is your email? [¿Cuál es tu dirección de correo electrónico?]* This field is required.We only need the email of the person filling out this form. We'll email you a confirmation of your request when you're finished.
example@example.com
Confirm Email
4
What is your full legal name? [¿Cuál es su nombre legal completo?]* This field is required.This should be your name when you visited this provider (maiden name, or other) [Este es el nombre que debes usar cuando visitaste este proveedor (apellido de soltera u otro)]
First Name
Last Name
5
What is your mailing address? [¿Cuál es su dirección postal?]* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
What is your date of birth? [¿Cuál es tu fecha de nacimiento?] (MM/DD/YYYY)* This field is required.
7
What is your relationship to the patient? [¿Cuál es su relación con el paciente?]* This field is required.
Parent
Caregiver / Legal Guardian [Cuidador / tutor lega]
Spouse [Esposo/Esposa]
8
Let's get your full name first. [Primero obtengamos su nombre completo.]* This field is required.Parent/Spouse/Caregiver's name only, NOT the patient's name [Nombre del padre/cónyuge/cuidador únicamente, NO el nombre del paciente]
First Name
Last Name
9
Upload supporting documentation [Cargar documentación de respaldo] (ie. Medical power of attorney, Medical Guardianship, Death Certificate) if applicable ****Parents who are listed on their child's medical record may skip this step. [**Los padres que figuran en el expediente médico de su hijo pueden omitir este paso.]
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
(ie. Medical power of attorney, Medical Guardianship, Death Certificate)
Cancelof
10
What is the patient's full legal name? [¿Cuál es el nombre legal completo del paciente?]* This field is required.This should be the patient's name when they visited this provider (maiden name, or other) [Este debe ser el nombre del paciente cuando visitó a este proveedor (apellido de soltera u otro)]
First Name
Last Name
11
What is the patient's mailing address? [¿Cuál es la dirección postal del paciente?]* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
What is the patient's date of birth? [¿Cuál es la fecha de nacimiento del paciente?] (MM/DD/YYYY)* This field is required.
13
What's the primary reason for requesting records? [¿Cuál es la razón principal para solicitar registros?]* This field is required.
Patient Request [Solicitud del paciente]
Continuation of Care [Continuación de la atención]
Other
14
From what timeframe are you looking for records? [¿A partir de qué período busca registros?]* This field is required.
All dates [Todas las fechas]
Custom dates [Fechas personalizadas]
15
From what timeframe are you looking for records? [¿A partir de qué período busca registros?]* This field is required.Oldest date - Most recent date [Fecha más antigua - Fecha más reciente]
MM/DD/YYYY - MM/DD/YYYY
16
Do you require a copy of your X-ray images? (no charge) [¿Necesita una copia de sus imágenes de rayos X? (sin cargo)]* This field is required.
YESNO
17
Which types of PAPER records would you like? [¿Qué tipos de registros de PAPEL le gustaría?]* This field is required.Check any that apply
Abstract/Visit Summary (recommended) [Resumen/Resumen de la visita (recomendado)]
History / Physical Report(s) [Historial / Informe(s) físico(s)]
Nursing home, home health, other physician records [Hogar de ancianos, atención médica domiciliaria y otros registros médicos]
Lab results, pathology reports, MRI Report [Resultados de laboratorio, informes de patología, informe de resonancia magnética.]
Itemized Billing Statements [Estados de cuenta detallados]
Operative Reports [Informes Operativos]
Ultrasound Images [Imágenes de ultrasonido]
Other
18
Please read each line and check each corresponding box [Por favor lea cada línea y marque cada casilla correspondiente.]* This field is required.Continuation of this form requires consent to all three sections [La continuación de este formulario requiere el consentimiento de las tres secciones.]
I authorize Evolve Health (formerly Modern Foot & Ankle) to release medical, mental, alcohol and/or drug abuse, HIV (human immunodeficiency virus), AIDS, eating disorders or any other medical information of a sensitive nature to the individual(s) or organization(s) I have specified. [Usted autoriza a Evolve Health (formerly Modern Foot & Ankle) a divulgar información médica, mental, abuso de alcohol y/o drogas, VIH (virus de inmunodeficiencia humana), SIDA, trastornos alimentarios o cualquier otra información médica de naturaleza sensible a las personas u organizaciones. ; he especificado.]
I understand that if the organization authorized to received the information is not a health plan or healthcare provider, the released information may no longer be protected by Federal privacy regulations. I understand that I need not sign this authorization to ensure treatment. This authorization shall remain valid for six months from the date signed. [Entiendo que si la organización autorizada para recibir la información no es un plan de salud o un proveedor de atención médica, es posible que la información divulgada ya no esté protegida por las regulaciones federales de privacidad. Entiendo que no necesito firmar esta autorización para garantizar el tratamiento. Esta autorización tendrá una vigencia de seis meses a partir de la fecha de su firma.]
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the department or facility listed on the authorization. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. [Entiendo que me reservo el derecho de revocar esta autorización en cualquier momento. Entiendo que si revoco esta autorización, debo hacerlo por escrito y presentar mi revocación por escrito al departamento o instalación que figura en la autorización. Entiendo que la revocación no se aplicará a la información que ya se haya divulgado en respuesta a esta autorización. Entiendo que la revocación no se aplicará a mi compañía de seguros cuando la ley le otorgue a mi aseguradora el derecho de impugnar un reclamo bajo mi póliza.]
19
To whom should we release these medical records? [¿A quién debemos revelar estos registros médicos?]* This field is required.
Me (the Patient) [Yo (el paciente)]
A third party (doctor, other) [Un tercero (médico, otro)]
A family member/caregiver [Un familiar/cuidador]
20
To whom should we release these medical records? [¿A quién debemos revelar estos registros médicos?]* This field is required.
The patient [The patient]
A third party (doctor, other) [Un tercero (médico, otro)]
Me, as a family member/caregiver [Yo, como familiar/cuidador]
21
How would you like us to send you your paper record? [¿Cómo le gustaría que le enviemos su registro en papel?]* This field is required.
Email (no charge) [Correo electrónico (sin cargo)]
Mail ($20 postage fee) [Correo ($20 de envío)]
I will pick them up (no charge) [Yo los recojo (sin cargo)]
22
How would you like us to send your paper record? [¿Cómo le gustaría que le enviemos su registro en papel?]* This field is required.
Email (no charge) [Correo electrónico (sin cargo)]
Fax (no charge) [Fax (sin cargo)]
Mail ($20 postage fee) [Correo ($20 de envío)]
23
How should we send the patient their paper records? [¿Cómo debemos enviar al paciente sus registros en papel?]* This field is required.
Email (no charge) [Correo electrónico (sin cargo)]
Mail ($20 postage fee) [Correo ($20 de envío)]
I or patient will pick them up (no charge) [Yo o el paciente los recogeremos (sin cargo)]
24
How should we send the patient's paper records? [¿Cómo debemos enviar los registros en papel del paciente?]* This field is required.
Email (no charge) [Correo electrónico (sin cargo)]
Fax (no charge) [Fax (sin cargo)]
Mail ($20 postage fee) [Correo ($20 de envío)]
25
Please confirm who these records should be released to: [Confirme a quién se deben divulgar estos registros:]* This field is required.If sending to yourself, this should be your name [Si te lo envías a ti mismo, este debe ser tu nombre.]
NAME/ORGANIZATION
26
Please confirm the email address to send records: [Confirme la dirección de correo electrónico para enviar registros en papel:]* This field is required.This is the email address you want records sent to [Esta es la dirección de correo electrónico a la que desea que se envíen los registros.]
example@example.com
Confirm Email
27
Please confirm the fax number to send paper records: [Confirme el número de fax para enviar registros en papel:]* This field is required.This is the fax number your want records sent to [Este es el número de fax al que desea que se envíen los registros.]
Please enter a valid phone number. [Por favor ingrese un número de teléfono válido.]
28
Please confirm where the paper records will be sent: [Confirme dónde se enviarán los registros en papel:]* This field is required.This is the address you want records sent to [Esta es la dirección a la que desea que se envíen los registros.]
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
29
Please choose which office you will pick up your records: [Elija en qué oficina recogerá sus registros:]* This field is required.Please visit the selected office at least 5 days after the completion of this form to receive your records. [Visite la oficina seleccionada al menos 5 días después de completar este formulario para recibir sus registros.]
Brandon office (540 Medical Oaks Ave, Suite 101, Brandon, FL 33511
Boynton Beach Office (8188 Jog Road, Ste. 205, Boynton Beach, FL 33472)
Casselberry office (178 Wilshire Blvd, Casselberry, FL 32707)
Celebration Office (1530 Celebration Boulevard, Suite 402, Celebration, FL 34747)
Clermont Office (301 Frontage Road, Ste B&C, Clermont, FL 34711)
Jupiter Office (1025 Military Trail, #208, Jupiter, FL 33458)
Kissimmee North Office/Hunter's Creek (3070 Loopdale Lane, Kissimmee, FL 34741)
Kissimmee South Office/Pleasant Hill (1508 Village Oak Ln, Kissimmee, FL 34746)
Lake Mary Office (2500 W. Lake Mary Blvd, Suite 210, Lake Mary, FL 32746)
Lake Nona Office (10016 Wellness Way, Unit 130, Orlando, FL 32832)
Lake Worth Office (4889 S. Congress Ave Suite 201 Lake Worth, FL 33461)
Largo Office (11200 Seminole Blvd, Ste 305 Largo, FL 33778)
Lutz Office (1005 Dale Mabry Hwy, Lutz, FL 33548)
Ocoee Office (2960 Maguire Rd, Ocoee, FL 34761)
Oviedo Office (1000 Executive Dr, Unit 9, Oviedo, FL 32765)
Port Richey Office (6709 Ridge Rd, Ste 204, Port Richey, FL 34668)
Sarasota Office (5741 Bee Ridge Road, Suite 490, Sarasota, FL 34233)
Spring Hill Office (10441 Quality Drive, Unit 103, Spring Hill, FL 34609)
St. Petersburg Office (560 Jackson Street N, Suite 120, St. Petersburg, FL 33705)
Tampa Habana Office (4700 N. Habana Avenue, Suite 400, Tampa, FL 33614)
Universal Office (5690 Windhover Dr, Orlando, FL 32819)
University Office (3500 E. Fletcher Avenue, Suite 133, Tampa, FL 33613)
Venice Office (400 S Tamiami Trail, Ste 170, Venice, FL 34285)
Wesley Chapel Office (5841 Argerian Dr, Ste 102 Wesley Chapel, FL 33545)
Westchase Office (10954 Sheldon Rd Tampa, FL 33626)
Winter Garden Office (15815 Shaddock Dr, Unit 130, Winter Garden, FL 34787)
Winter Park Office (201 Moray Lane, Winter Park, FL 32792)
Cypress (Texas) Office (12300 Dundee Ct, Suite 213, Cypress, TX 77429)
Katy (Texas) Office (21401 Provincial Blvd, Ste A, Katy, TX 77450)
Post Oak (Texas) Office (4801 Woodway Drive, Suite 105E Houston, TX 77056)
Spring (Texas) Office (2616 Farm to Market 2920 Suite N, Spring, TX 77388)
Spring Branch (Texas) Office (9055 Katy Freeway Suite 460 Houston, TX 77024)
Sugarland (Texas) Office (15200 Southwest Fwy, Suite 250, Sugar Land, TX 77478)
The Woodlands (Texas) Office (1001 Medical Plaza Drive, Suite 220, The Woodlands, Texas 77380 )
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X-Rays are in disc format must be picked up by the individual completing this form. Which office would you like to pick up the x-ray disc? [Las radiografías que están en formato de disco deben ser recogidas por la persona que completa este formulario. ¿En qué oficina le gustaría recoger el disco de rayos X?]* This field is required.Please visit the selected office at least 5 days after the completion of this form to receive your x-ray disc [Visite la oficina seleccionada al menos 5 días después de completar este formulario para recibir su disco de rayos X.]
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Jupiter Office (1025 Military Trail, #208, Jupiter, FL 33458)
Kissimmee North Office/Hunter's Creek (3070 Loopdale Lane, Kissimmee, FL 34741)
Kissimmee South Office/Pleasant Hill (1508 Village Oak Ln, Kissimmee, FL 34746)
Lake Mary Office (2500 W. Lake Mary Blvd, Suite 210, Lake Mary, FL 32746)
Lake Nona Office (10016 Wellness Way, Unit 130, Orlando, FL 32832)
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Largo Office (11200 Seminole Blvd, Ste 305 Largo, FL 33778)
Lutz Office (1005 Dale Mabry Hwy, Lutz, FL 33548)
Ocoee Office (2960 Maguire Rd, Ocoee, FL 34761)
Oviedo Office (1000 Executive Dr, Unit 9, Oviedo, FL 32765)
Port Richey Office (6709 Ridge Rd, Ste 204, Port Richey, FL 34668)
Sarasota Office (5741 Bee Ridge Road, Suite 490, Sarasota, FL 34233)
Spring Hill Office (10441 Quality Drive, Unit 103, Spring Hill, FL 34609)
St. Petersburg Office (560 Jackson Street N, Suite 120, St. Petersburg, FL 33705)
Tampa Habana Office (4700 N. Habana Avenue, Suite 400, Tampa, FL 33614)
Universal Office (5690 Windhover Dr, Orlando, FL 32819)
University Office (3500 E. Fletcher Avenue, Suite 133, Tampa, FL 33613)
Venice Office (400 S Tamiami Trail, Ste 170, Venice, FL 34285)
Wesley Chapel Office (5841 Argerian Dr, Ste 102 Wesley Chapel, FL 33545)
Westchase Office (10954 Sheldon Rd Tampa, FL 33626)
Winter Garden Office (15815 Shaddock Dr, Unit 130, Winter Garden, FL 34787)
Winter Park Office (201 Moray Lane, Winter Park, FL 32792)
Cypress (Texas) Office (12300 Dundee Ct, Suite 213, Cypress, TX 77429)
Katy (Texas) Office (21401 Provincial Blvd, Ste A, Katy, TX 77450)
Post Oak (Texas) Office (4801 Woodway Drive, Suite 105E Houston, TX 77056)
Spring (Texas) Office (2616 Farm to Market 2920 Suite N, Spring, TX 77388)
Spring Branch (Texas) Office (9055 Katy Freeway Suite 460 Houston, TX 77024)
Sugarland (Texas) Office (15200 Southwest Fwy, Suite 250, Sugar Land, TX 77478)
The Woodlands (Texas) Office (1001 Medical Plaza Drive, Suite 220, The Woodlands, Texas 77380 )
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CALC
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Calc 2
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Fees for medical records DUE TODAY [Mail records ($20)]. You will be prompted on the next screen to pay by our secure payment processor, Square. [Tarifas por registros médicos que DEBEN HOY [registros por correo ($20)]. En la siguiente pantalla, nuestro procesador de pagos seguro, Square, le solicitará que pague.]* This field is required.Required for submission of release form. You agree to have your card charged once for the processing of medical records. Once payment has been processed, please allow our staff 48-72 hours to prepare your records request. [Requerido para la presentación del formulario de autorización. Usted acepta que se le cobre a su tarjeta una vez por el procesamiento de registros médicos. Una vez que se haya procesado el pago, permita que nuestro personal tenga entre 48 y 72 horas para preparar su solicitud de registros.]
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For verification purposes, please upload a picture of your driver's license [Para fines de verificación, cargue una fotografía de su licencia de conducir.]Front of license only required [Solo se requiere el frente de la licencia]
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Signature To Authorize Sending Of Protected Health Information (PHI)* This field is required.I authorize Evolve Health (formerly Modern Foot & Ankle) to send my medical records, including protected health information (PHI), via the communication method selected above. I understand that email is not a secure method of transmission and may be intercepted or accessed by unauthorized parties. I accept this risk and consent to receive my records via email, if requested. I understand I may revoke this authorization at any time in writing, and that this authorization will expire one year from the date of signing unless otherwise specified.
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