Cardiology Associates of Boca Raton
David S. Funt, M.D., P.A., F.A.C.C.
Jay F. Baker, M.D., P.A., F.A.C.C.
Constance D. Fields, M.D., F.A.C.C.
Steven M. Coletti, M.D., F.A.C.C.
Ronald M. Gabor, M.D., F.A.C.C.
West Boca Medical Center Professional Bldg.
9980 Central Park Blvd. N., #304
Boca Raton, Florida 33428
PHONE (561) 483-8335 •
Boynton Beach Medical Plaza
10151 Enterprise Center Blvd., # 203
Boynton Beach, Fl 33437
FAX (561) 483-1756
DATE:
___________________
TO:
______________________________________________________
TO WHOM IT MAY CONCERN:
Enclosed please find your request for medical records. It is our office policy that
there be a signature from the patient authorizing us to release medical records.
Doctors at Cardiology Associates of Boca Raton do not charge for duplication and
processing of patient medical records and/or narrative reports for all Attending
Physician Statements.
Your request for records will be met, once we have received the request information
and/or fee.
Patient Name: __________________________
Patient No.: ________________
Your file/report consist of ___________pages.
First twenty-five pages @ $1.00 per pages $1.00 x _____ pages = $ ______________
Additional pages @ $0.25 per pages
$0.25 x _____ pages = $ ______________
Miscellaneous fees (freight, forms, stamps,letters)
$ ______________
Archive Retrieval Fee
$ ______________
CD’s
$ ______________
Plus Outstanding Account Balance
$______________
TOTAL AMOUNT DUE:
$ ______________
Please remit the full amount as shown above. Upon receipt of payment and signed
authorization, records will be forwarded. PLEASE MAKE CHECK PAYABLE TO:
CARDIOLOGY ASSOCIATES OF BOCA RATON.
If you have any questions feel free to contact our medical records office at 591-4838335.
Thank you, Custodian Medical Records