Last Name*
First Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Phone Number*
Reason for requesting records: Other*
Entity 1* Select one Doctor Self Attorney Insurance Disability/Social Security Other
Name 1*
Fax #/Mailing Address 1/Email*
Entity 2 Select one Doctor Self Attorney Insurance Disability/Social Security Other
Name 2
Fax #/Mailing Address 2/Email
Lab Results Date Range - Start
Date Format: MM slash DD slash YYYY
Lab Results Date Range - End
Date Format: MM slash DD slash YYYY
X-Ray Date Range - Start
Date Format: MM slash DD slash YYYY
X-Ray Date Range - End
Date Format: MM slash DD slash YYYY
Type of Information Other*
Encounter 1 Select Doctor or Medical Specialty Nathan Meyer, PharmD Mazen A. Abboud, DPM Sameer Ahmed, MD Sujani Akkineni, MD, HMDC Ambreen Alam, DO Kelsey Alcocer, OD Alejandro Cintas, MD “Trey” Gerald Alexander, III, MD Jeralyn A. Allen, MD Kathryn Anderson, MD C. Nancy Anise, MD Kimberly Apple, MD, FACS Hal J. Applebaum, MD, FACC Mark L. Arey, MD Douglas Baska, DO Colin S. Beach, MD Rafael Blasini, MD Michael Branch, MD Antonio Bunker-Huertas, MD Allison R. Burton, MD Richard Bymaster, MD Diana C. Calderone, MD William Capo, MD, FACC Joseph S. Caradonna, MD Carlos Cardenas, MD Rachel Careccia, MD Carrie A. Downey, DO S. Bill Carter, MD Alejandro Carvallo, MD, FACP Norman Castellano, MD Thomas Castillenti, DO Elvis Castillo-Garcia, MD, CWSP Juan Cevallos, MD Sirisha Chalasani, MD Tawfik Chami, MD George R. Cheeseman, III, MD Paul Citrin, MD, FACS Whalen Clark, MD, FACS Joseph S. Cody, MD Timothy J. Connor, MD Seth Cooper, MD Yamitza Cordero-Ferrer, MD, FACP, BS Leonard Cortelli, Jr., MD Joseph Cozzolino, MD, MBA Geoffrey Cronen, MD Vladimir Curkovic, MD, FACC Gerald V. Curley, DO Resham Datta, MD George R. Davis, DO Veronica C. Davis, DO Jacqui Dawson, DO, ACOFP Maria DeCastro, DO Beverly Deliz-Tirado, MD Manjul Derasari, MD, PA Vijay M. Desai, MD Lisa M. Diaz, DO, FAAD Marianne Diego-Wright, MD Jon DiPietro, MD Nathan M. Do, MD, FCCP Brian C. Domby, MD Emilio Dominguez, MD Theron A. Ebel, MD, FACP, FCCP Mark Eisner, MD Shweta Ekka, MD Lowella Esperanza, MD Anthony Esposito, DO Natalie Faith, MD, RhMSUS, RMSK Dennis H. Feldman, MD Alicia Fierro, DO Fabiola Figueroa, MBA, RD, CDE Astrid Figueroa, DO Tomas Figueroa-Nieves, MD Nancy Finnerty, MD, PhD Lucretia Fisher, MD, HMDC Hector L. Fontanet, MD, FACC Mitchell Forman, MD Barry Frank, MD Christopher Garcia, MD Roger “Casey” Gaskins, III, MD Paul Z. Gerczuk, MD Robert P. Gilbert, MD Angel R. Gonzalez, MD Eduardo Gonzalez-Perez, MD Edmund G. Grant, Jr., MD Richard Gray, MD Daniel Guild, OD Annilea Gunn, MD, CCFP, FCFP A.R. Gutierrez, III, DO Ira Guttentag, MD, FACS Matthew T. Hartlage, MD David R. Heiman, MD Belen M. Herrero-Mujic, MD Joseph Hubaykah, MD Paul Hughes, MD, JD Allison Hull, DO Ronald “Tripp” Hulse, MD Richard J. Ina, MD, AAFP, ABFM Sajid Ismail, DO Imran Ismail, DO M. Gerard Jackson, MD, FACOG Jennifer Jain, MD Julio A. Gonzalez-Paoli, MD Somasekhara Kaipu, MD Kanchan N Kamath, MD Samir Kapoor, MD, FRCS Imran Kayani, MD Sohail Khan, MD Barkat U. Khan, MD Allauddin Khan, MD Tomas Korensky, MD Sujal Kotadia, MD Yuvraj Kumbkarni, MD Anjum Kumbkarni, MD, MBA Shana Laflin, MD Sean Lannon, MD Todd LaRue, MD Debra Lastarria, MD Nigel Lewis, MD Arlene D. Lobo, MD, FACC Jonathan C. Lohrbach, MD, FACS Edwin Lopez-Chaves, MD Roshan Mahtani, MD Martin Maldonado, MD, FACG Frederick M. Malibiran, DO Shifa H. Malik, MD Veronica Mardo, MD Carlos C. Marinelli, MD, FACC Morayma Martinez, MD Ajay Mathew, DO Earl W. McAllister, MD, FACS Richard F. McDonough, MD Tracy McKay, DO Roberto P. Medina, MD, FACC Luis A. Melendez-Collazo, MD Marian F. Menezes, MD, FCCP Naresh Menezes, MD Lakshmi Menezes, MD Andrew Messina, MD Lance R. Meyerson, MD, FACS Shashank Mishra, MD Michael Montuno, MD Anetha Moorthal, MD Reynaldo Mulingtapang, MD, FACC Daniel E. Murphy, MD Sameer H. Nagamia, MD Sami Nallamshetty, MD, FACAAI Charles “Chuck” Nalley, MD Florence Nappi, MD Phuong Nguyen, MD Marty W. Odom, MD Catherine Paltoo, MD Santo Paniello, MD, FACOG Kanchan Parasher, MD Vijay Patel, MD Pankaj Patel, MD Niraj Patel, MD, FACOG Mikin Patel, MD Manuel C. Sáinz de la Peña, MD Paul Phillips, DO Parag Pitroda, MD J. Kevin Poitras, MD Jesal V. Popat, MD, FACC Gilbert Postler, MD Ricardo Prieto, MD Allen Pusateri, MD Thomas Pusateri, MD Sivaram Rajan, MD Arnold M. Ramirez, MD Stephen Raterman, MD, FACS Daniel A. Reichmuth, MD, FAAAAI, FACAAI Samina Reza, MD David Rivera, MD Mayra M. Rivera, MD Michael "Giles" Roberts, DO Daniel Rodriguez, MD Ernesto Rodriguez-Velazquez, MD, RhMSUS Keith Alexander Rosenbach, MD, PhD Abhik Roy, MD Rene Santoscoy, MD Chandresh Saraiya, MD Vanessa Sarquis, MD Sam E. Scolaro, DO Jeffrey See, MD Sailesh N. Shah, DO, FCCP Chirag Shah, DO Sejal Shah, MD Shaily Shah, DO R. David Shepard, MD David Sikes, MD Soloman R. Singh, MD Frank A. Sirchia, MD Joel Sokolik, MD Gabriel J. Somori, MD Yamira Soto, MD James A. Sotrop, MD Christopher G. Spanich, MD Megan Spencer, MD Katherine Standley, DO Jason Stanton, MD Cicily Stanton, MD John Thompson Sullebarger, MD Brent C. Sullivan, MD Sravan Thangeda, MD Robert J. Theobald, III, DO Andrea Tordini, MD Amarilis Torres, MD Maulik K. Trivedi, MD Sonia D. V. Trzmielina, MD Petros Tsambiras, MD Jessica Valenti, MD Suresh Vemuri, MD Rohit K. Vyas, MD Ravikanth Vydyula, MD Stanley Watkins, MD Jennifer Wetherington, MD Jennifer White, MD Thomas W. Woodrow, MD, FACC Mark J. Yockey, MD James Zaccari, DO Alyssa Zwarych, MD Julie G. Lewerenz, Au.D. Sierra MacDonald, Au.D. Jennifer Miller, Au.D. Natalie Abell, PA-C Alexis Prickett Adams, PA-C Tina Agostinelli, PA-C Akosua Agyemang, APRN, DNP Crystal Alshamai, PA-C Kelli Anzalone, APRN Christina Arnold, PA-C Benise Artus, MS, APRN-C Xiomara Matias Ayala, APRN Erin Barowski, MSN, APRN, FNP-BC Sherdene Barrett, APRN James Bishop, PA-C Jennifer Boatwright, PA-C Boris Borissov, APRN Matthew Brice, PA-C Lindsey Broadnax, PA-C Stefanie Caggiano, APRN Robert Carr, PA-C Brandy Centers, APRN Lee Chatham, APRN Anne Clark, APRN-BC, MS Deborah Collura, MS, APRN-BC, MBA Stephanie Commet, APRN, MSN, AGACNP-BC Heidi Cook, APRN Selena Crandall, MSN, APRN Rachel Odioso Cruz, PA-C Marian Dam, DNP, APRN-BC, CDE Stephanie Delvaux, APRN Anne Dempsey, APRN-BC Dimple Desai, PA-C, MMSc, MT Sara Dominic, APRN-BC Nicole Donovan, PA-C Sarah Drapela, CNM, APRN Nadia Etienne, APRN Kyle Eury, MSN, APRN Sheena Eversole, APRN, MSN-FNP Benjamin Feldman, PA-C Luz Figueroa-Escalera, MSN, APRN Rebecca Fisher, PA-C Amanda Fitch Nagy, APRN Khristel Fonseca-Miller, APRN, NP-C Erica Franchick, PA-C Lisa Gavosto, APRN, NP-C Susan Gibbs, APRN Joshua Gilliam, PA-C, ATC Erin Godlewski, APRN-BC Alicia Grigsby, APRN-BC Ashley Gruber, MS, APRN, FNP-C, CMSRN Sarah L. Hamlin, APRN, MSN Stephanie Hampton, MSPAS, PA-C Mary Hanley, APRN April Hatfield, APRN Lisa Hayes, PA-C Tina Heinrich, MS, APRN Joan Heitzler, APRN, ANP-BC Amie Hellman, APRN Tamara Holmes, MSN, ARNP-C Jessica Hahn Hutchins, APRN Skyler Jacobs, CNM JonAnne Jameson, APRN Nan Jameson-Lee, APRN Meggan Jaramillo, CNM Debra Jeakle, APRN-CS Diana Cristina Jennings, MSN, APRN, FNP-C Marissa Johnson, MSN, APRN, FNP-BC Ashley Johnston, PA-C Jessica Kokich, APRN Rebecca Kraft, APRN Michele Laine, MSN, APRN-BC, CDE Erin Lange-Vandello, MS, PA-C Meghan LaRose, PA-C Beth Ann Leaf, PA-C Mextli Lermont-Ortiz, MPAS, PA-C Heather Leto, APRN, FNP-C Kelly Lidz, APRN, PMHNP-BC Cori Lloyd, APRN, DNP, WHNP-BC Brittany Loringer, PA-C Romainda Lubin, APRN-C John Paul Ludovice, APRN Glenn MacLean, PA-C Sasha Madden, APRN Danay Marante, MS, PA-C Meghan Maritato, APRN-BC Emily Martin, PA-C Julie Martinez, MSN, FNP-BC Maxx Ramirez, PA-C, MPAS Erin McDonough, APRN, DNP John McGowan, PA-C Brittany Mertz, PA-C Melissa Miranda-Luciano, APRN-C Neda Moghadasi, APRN-C, MSN Darlene Montani, MSN, APRN, FNP-BC, ONC BrettAshley Montero, APRN Diana Moorer, APRN, FNP-BC Rita Morgan, APRN-BC Nickeya Murphy DNP, APRN, FNP-C Brian Nagel, PA-C Melissa Nihiser, APRN, NP-C Tracey Nimeh, PA-C Julie Norton, APRN Caitlin M. Odom, PA-C Karen Olivero, MMS, PA-C Scarlette Owens, APRN-C, MSN Patricia Pamas, APRN, FNP-C Alise Pastorik, APRN, DHSc-BC, MS Bhumika Patel, PA-C Dee Perez, APRN Francine Phillips, MPAS, PA-C Cristina Relihan, PA-C Lauren Ruff, PA-C Cheryl Rumph, APRN, AGACNP-BC R. Scott Scheirer, APRN-BC, MSN Heather Schryver, APRN-BC Kjersti Sikes, APRN-BC, PMHNP-BC Jasmine Siska, PA-C Barbara Smith, APRN Shannon Smith, APRN Christina Stieber, PA-C Amanda Sturgeon, APRN, MSN, FNP-BC Stephanie Symonds, APRN, PMHNP-BC Laura J. Szydlowski, APRN-BC Sajedah Taher, DNP, APRN-BC Leah Terry, APRN, FNP-C Ratchadakon "Pat" Tran, MSN, APRN Joanie Turner, CNM, APRN Barbara Vargas, PA-C Brittany Villa, MS, APRN-C Julie Vining, APRN, NP-C Amber Vogt, APRN Erik Wells, APRN-BC Danielle Williamson, APRN, NP-C Lauren Yates, PA-C Nadia Zhylin, APRN, FNP-BC Allergy, Asthma & Immunology Ambulatory Surgery Centers Anesthesiology Audiology & Hearing Aids Cardiology Dermatology Diagnostic Laboratory Endocrinology Gastroenterology Hematology & Medical Oncology Hospital Medicine Infectious Diseases & Wound Care Infusion Services Interventional Pain Management Nephrology Neurology Non-Interventional Pain Management Nutrition & Diabetes Education Obstetrics, Gynecology & Midwifery Ophthalmology Optometry Orthopaedics, Sports Medicine & Spine Otolaryngology - Ear, Nose & Throat Palliative Care Pathology Pediatrics Pharmacy Physical Therapy Podiatry Primary Care Proctology Psychiatry & Behavioral Health Pulmonology & Sleep Disorders Radiology Rheumatology Spine Surgery Surgery Urgent Care Urology Vascular Surgery Well-Being Program
Date Range - Start
Date Format: MM slash DD slash YYYY
Date Range - End
Date Format: MM slash DD slash YYYY
Encounter 2 Select Doctor or Medical Specialty Nathan Meyer, PharmD Mazen A. Abboud, DPM Sameer Ahmed, MD Sujani Akkineni, MD, HMDC Ambreen Alam, DO Kelsey Alcocer, OD Alejandro Cintas, MD “Trey” Gerald Alexander, III, MD Jeralyn A. Allen, MD Kathryn Anderson, MD C. Nancy Anise, MD Kimberly Apple, MD, FACS Hal J. Applebaum, MD, FACC Mark L. Arey, MD Douglas Baska, DO Colin S. Beach, MD Rafael Blasini, MD Michael Branch, MD Antonio Bunker-Huertas, MD Allison R. Burton, MD Richard Bymaster, MD Diana C. Calderone, MD William Capo, MD, FACC Joseph S. Caradonna, MD Carlos Cardenas, MD Rachel Careccia, MD Carrie A. Downey, DO S. Bill Carter, MD Alejandro Carvallo, MD, FACP Norman Castellano, MD Thomas Castillenti, DO Elvis Castillo-Garcia, MD, CWSP Juan Cevallos, MD Sirisha Chalasani, MD Tawfik Chami, MD George R. Cheeseman, III, MD Paul Citrin, MD, FACS Whalen Clark, MD, FACS Joseph S. Cody, MD Timothy J. Connor, MD Seth Cooper, MD Yamitza Cordero-Ferrer, MD, FACP, BS Leonard Cortelli, Jr., MD Joseph Cozzolino, MD, MBA Geoffrey Cronen, MD Vladimir Curkovic, MD, FACC Gerald V. Curley, DO Resham Datta, MD George R. Davis, DO Veronica C. Davis, DO Jacqui Dawson, DO, ACOFP Maria DeCastro, DO Beverly Deliz-Tirado, MD Manjul Derasari, MD, PA Vijay M. Desai, MD Lisa M. Diaz, DO, FAAD Marianne Diego-Wright, MD Jon DiPietro, MD Nathan M. Do, MD, FCCP Brian C. Domby, MD Emilio Dominguez, MD Theron A. Ebel, MD, FACP, FCCP Mark Eisner, MD Shweta Ekka, MD Lowella Esperanza, MD Anthony Esposito, DO Natalie Faith, MD, RhMSUS, RMSK Dennis H. Feldman, MD Alicia Fierro, DO Fabiola Figueroa, MBA, RD, CDE Astrid Figueroa, DO Tomas Figueroa-Nieves, MD Nancy Finnerty, MD, PhD Lucretia Fisher, MD, HMDC Hector L. Fontanet, MD, FACC Mitchell Forman, MD Barry Frank, MD Christopher Garcia, MD Roger “Casey” Gaskins, III, MD Paul Z. Gerczuk, MD Robert P. Gilbert, MD Angel R. Gonzalez, MD Eduardo Gonzalez-Perez, MD Edmund G. Grant, Jr., MD Richard Gray, MD Daniel Guild, OD Annilea Gunn, MD, CCFP, FCFP A.R. Gutierrez, III, DO Ira Guttentag, MD, FACS Matthew T. Hartlage, MD David R. Heiman, MD Belen M. Herrero-Mujic, MD Joseph Hubaykah, MD Paul Hughes, MD, JD Allison Hull, DO Ronald “Tripp” Hulse, MD Richard J. Ina, MD, AAFP, ABFM Sajid Ismail, DO Imran Ismail, DO M. Gerard Jackson, MD, FACOG Jennifer Jain, MD Julio A. Gonzalez-Paoli, MD Somasekhara Kaipu, MD Kanchan N Kamath, MD Samir Kapoor, MD, FRCS Imran Kayani, MD Sohail Khan, MD Barkat U. Khan, MD Allauddin Khan, MD Tomas Korensky, MD Sujal Kotadia, MD Yuvraj Kumbkarni, MD Anjum Kumbkarni, MD, MBA Shana Laflin, MD Sean Lannon, MD Todd LaRue, MD Debra Lastarria, MD Nigel Lewis, MD Arlene D. Lobo, MD, FACC Jonathan C. Lohrbach, MD, FACS Edwin Lopez-Chaves, MD Roshan Mahtani, MD Martin Maldonado, MD, FACG Frederick M. Malibiran, DO Shifa H. Malik, MD Veronica Mardo, MD Carlos C. Marinelli, MD, FACC Morayma Martinez, MD Ajay Mathew, DO Earl W. McAllister, MD, FACS Richard F. McDonough, MD Tracy McKay, DO Roberto P. Medina, MD, FACC Luis A. Melendez-Collazo, MD Marian F. Menezes, MD, FCCP Naresh Menezes, MD Lakshmi Menezes, MD Andrew Messina, MD Lance R. Meyerson, MD, FACS Shashank Mishra, MD Michael Montuno, MD Anetha Moorthal, MD Reynaldo Mulingtapang, MD, FACC Daniel E. Murphy, MD Sameer H. Nagamia, MD Sami Nallamshetty, MD, FACAAI Charles “Chuck” Nalley, MD Florence Nappi, MD Phuong Nguyen, MD Marty W. Odom, MD Catherine Paltoo, MD Santo Paniello, MD, FACOG Kanchan Parasher, MD Vijay Patel, MD Pankaj Patel, MD Niraj Patel, MD, FACOG Mikin Patel, MD Manuel C. Sáinz de la Peña, MD Paul Phillips, DO Parag Pitroda, MD J. Kevin Poitras, MD Jesal V. Popat, MD, FACC Gilbert Postler, MD Ricardo Prieto, MD Allen Pusateri, MD Thomas Pusateri, MD Sivaram Rajan, MD Arnold M. Ramirez, MD Stephen Raterman, MD, FACS Daniel A. Reichmuth, MD, FAAAAI, FACAAI Samina Reza, MD David Rivera, MD Mayra M. Rivera, MD Michael "Giles" Roberts, DO Daniel Rodriguez, MD Ernesto Rodriguez-Velazquez, MD, RhMSUS Keith Alexander Rosenbach, MD, PhD Abhik Roy, MD Rene Santoscoy, MD Chandresh Saraiya, MD Vanessa Sarquis, MD Sam E. Scolaro, DO Jeffrey See, MD Sailesh N. Shah, DO, FCCP Chirag Shah, DO Sejal Shah, MD Shaily Shah, DO R. David Shepard, MD David Sikes, MD Soloman R. Singh, MD Frank A. Sirchia, MD Joel Sokolik, MD Gabriel J. Somori, MD Yamira Soto, MD James A. Sotrop, MD Christopher G. Spanich, MD Megan Spencer, MD Katherine Standley, DO Jason Stanton, MD Cicily Stanton, MD John Thompson Sullebarger, MD Brent C. Sullivan, MD Sravan Thangeda, MD Robert J. Theobald, III, DO Andrea Tordini, MD Amarilis Torres, MD Maulik K. Trivedi, MD Sonia D. V. Trzmielina, MD Petros Tsambiras, MD Jessica Valenti, MD Suresh Vemuri, MD Rohit K. Vyas, MD Ravikanth Vydyula, MD Stanley Watkins, MD Jennifer Wetherington, MD Jennifer White, MD Thomas W. Woodrow, MD, FACC Mark J. Yockey, MD James Zaccari, DO Alyssa Zwarych, MD Julie G. Lewerenz, Au.D. Sierra MacDonald, Au.D. Jennifer Miller, Au.D. Natalie Abell, PA-C Alexis Prickett Adams, PA-C Tina Agostinelli, PA-C Akosua Agyemang, APRN, DNP Crystal Alshamai, PA-C Kelli Anzalone, APRN Christina Arnold, PA-C Benise Artus, MS, APRN-C Xiomara Matias Ayala, APRN Erin Barowski, MSN, APRN, FNP-BC Sherdene Barrett, APRN James Bishop, PA-C Jennifer Boatwright, PA-C Boris Borissov, APRN Matthew Brice, PA-C Lindsey Broadnax, PA-C Stefanie Caggiano, APRN Robert Carr, PA-C Brandy Centers, APRN Lee Chatham, APRN Anne Clark, APRN-BC, MS Deborah Collura, MS, APRN-BC, MBA Stephanie Commet, APRN, MSN, AGACNP-BC Heidi Cook, APRN Selena Crandall, MSN, APRN Rachel Odioso Cruz, PA-C Marian Dam, DNP, APRN-BC, CDE Stephanie Delvaux, APRN Anne Dempsey, APRN-BC Dimple Desai, PA-C, MMSc, MT Sara Dominic, APRN-BC Nicole Donovan, PA-C Sarah Drapela, CNM, APRN Nadia Etienne, APRN Kyle Eury, MSN, APRN Sheena Eversole, APRN, MSN-FNP Benjamin Feldman, PA-C Luz Figueroa-Escalera, MSN, APRN Rebecca Fisher, PA-C Amanda Fitch Nagy, APRN Khristel Fonseca-Miller, APRN, NP-C Erica Franchick, PA-C Lisa Gavosto, APRN, NP-C Susan Gibbs, APRN Joshua Gilliam, PA-C, ATC Erin Godlewski, APRN-BC Alicia Grigsby, APRN-BC Ashley Gruber, MS, APRN, FNP-C, CMSRN Sarah L. Hamlin, APRN, MSN Stephanie Hampton, MSPAS, PA-C Mary Hanley, APRN April Hatfield, APRN Lisa Hayes, PA-C Tina Heinrich, MS, APRN Joan Heitzler, APRN, ANP-BC Amie Hellman, APRN Tamara Holmes, MSN, ARNP-C Jessica Hahn Hutchins, APRN Skyler Jacobs, CNM JonAnne Jameson, APRN Nan Jameson-Lee, APRN Meggan Jaramillo, CNM Debra Jeakle, APRN-CS Diana Cristina Jennings, MSN, APRN, FNP-C Marissa Johnson, MSN, APRN, FNP-BC Ashley Johnston, PA-C Jessica Kokich, APRN Rebecca Kraft, APRN Michele Laine, MSN, APRN-BC, CDE Erin Lange-Vandello, MS, PA-C Meghan LaRose, PA-C Beth Ann Leaf, PA-C Mextli Lermont-Ortiz, MPAS, PA-C Heather Leto, APRN, FNP-C Kelly Lidz, APRN, PMHNP-BC Cori Lloyd, APRN, DNP, WHNP-BC Brittany Loringer, PA-C Romainda Lubin, APRN-C John Paul Ludovice, APRN Glenn MacLean, PA-C Sasha Madden, APRN Danay Marante, MS, PA-C Meghan Maritato, APRN-BC Emily Martin, PA-C Julie Martinez, MSN, FNP-BC Maxx Ramirez, PA-C, MPAS Erin McDonough, APRN, DNP John McGowan, PA-C Brittany Mertz, PA-C Melissa Miranda-Luciano, APRN-C Neda Moghadasi, APRN-C, MSN Darlene Montani, MSN, APRN, FNP-BC, ONC BrettAshley Montero, APRN Diana Moorer, APRN, FNP-BC Rita Morgan, APRN-BC Nickeya Murphy DNP, APRN, FNP-C Brian Nagel, PA-C Melissa Nihiser, APRN, NP-C Tracey Nimeh, PA-C Julie Norton, APRN Caitlin M. Odom, PA-C Karen Olivero, MMS, PA-C Scarlette Owens, APRN-C, MSN Patricia Pamas, APRN, FNP-C Alise Pastorik, APRN, DHSc-BC, MS Bhumika Patel, PA-C Dee Perez, APRN Francine Phillips, MPAS, PA-C Cristina Relihan, PA-C Lauren Ruff, PA-C Cheryl Rumph, APRN, AGACNP-BC R. Scott Scheirer, APRN-BC, MSN Heather Schryver, APRN-BC Kjersti Sikes, APRN-BC, PMHNP-BC Jasmine Siska, PA-C Barbara Smith, APRN Shannon Smith, APRN Christina Stieber, PA-C Amanda Sturgeon, APRN, MSN, FNP-BC Stephanie Symonds, APRN, PMHNP-BC Laura J. Szydlowski, APRN-BC Sajedah Taher, DNP, APRN-BC Leah Terry, APRN, FNP-C Ratchadakon "Pat" Tran, MSN, APRN Joanie Turner, CNM, APRN Barbara Vargas, PA-C Brittany Villa, MS, APRN-C Julie Vining, APRN, NP-C Amber Vogt, APRN Erik Wells, APRN-BC Danielle Williamson, APRN, NP-C Lauren Yates, PA-C Nadia Zhylin, APRN, FNP-BC Allergy, Asthma & Immunology Ambulatory Surgery Centers Anesthesiology Audiology & Hearing Aids Cardiology Dermatology Diagnostic Laboratory Endocrinology Gastroenterology Hematology & Medical Oncology Hospital Medicine Infectious Diseases & Wound Care Infusion Services Interventional Pain Management Nephrology Neurology Non-Interventional Pain Management Nutrition & Diabetes Education Obstetrics, Gynecology & Midwifery Ophthalmology Optometry Orthopaedics, Sports Medicine & Spine Otolaryngology - Ear, Nose & Throat Palliative Care Pathology Pediatrics Pharmacy Physical Therapy Podiatry Primary Care Proctology Psychiatry & Behavioral Health Pulmonology & Sleep Disorders Radiology Rheumatology Spine Surgery Surgery Urgent Care Urology Vascular Surgery Well-Being Program
Date Range - Start
Date Format: MM slash DD slash YYYY
Date Range - End
Date Format: MM slash DD slash YYYY
Encounter 3 Select Doctor or Medical Specialty Nathan Meyer, PharmD Mazen A. Abboud, DPM Sameer Ahmed, MD Sujani Akkineni, MD, HMDC Ambreen Alam, DO Kelsey Alcocer, OD Alejandro Cintas, MD “Trey” Gerald Alexander, III, MD Jeralyn A. Allen, MD Kathryn Anderson, MD C. Nancy Anise, MD Kimberly Apple, MD, FACS Hal J. Applebaum, MD, FACC Mark L. Arey, MD Douglas Baska, DO Colin S. Beach, MD Rafael Blasini, MD Michael Branch, MD Antonio Bunker-Huertas, MD Allison R. Burton, MD Richard Bymaster, MD Diana C. Calderone, MD William Capo, MD, FACC Joseph S. Caradonna, MD Carlos Cardenas, MD Rachel Careccia, MD Carrie A. Downey, DO S. Bill Carter, MD Alejandro Carvallo, MD, FACP Norman Castellano, MD Thomas Castillenti, DO Elvis Castillo-Garcia, MD, CWSP Juan Cevallos, MD Sirisha Chalasani, MD Tawfik Chami, MD George R. Cheeseman, III, MD Paul Citrin, MD, FACS Whalen Clark, MD, FACS Joseph S. Cody, MD Timothy J. Connor, MD Seth Cooper, MD Yamitza Cordero-Ferrer, MD, FACP, BS Leonard Cortelli, Jr., MD Joseph Cozzolino, MD, MBA Geoffrey Cronen, MD Vladimir Curkovic, MD, FACC Gerald V. Curley, DO Resham Datta, MD George R. Davis, DO Veronica C. Davis, DO Jacqui Dawson, DO, ACOFP Maria DeCastro, DO Beverly Deliz-Tirado, MD Manjul Derasari, MD, PA Vijay M. Desai, MD Lisa M. Diaz, DO, FAAD Marianne Diego-Wright, MD Jon DiPietro, MD Nathan M. Do, MD, FCCP Brian C. Domby, MD Emilio Dominguez, MD Theron A. Ebel, MD, FACP, FCCP Mark Eisner, MD Shweta Ekka, MD Lowella Esperanza, MD Anthony Esposito, DO Natalie Faith, MD, RhMSUS, RMSK Dennis H. Feldman, MD Alicia Fierro, DO Fabiola Figueroa, MBA, RD, CDE Astrid Figueroa, DO Tomas Figueroa-Nieves, MD Nancy Finnerty, MD, PhD Lucretia Fisher, MD, HMDC Hector L. Fontanet, MD, FACC Mitchell Forman, MD Barry Frank, MD Christopher Garcia, MD Roger “Casey” Gaskins, III, MD Paul Z. Gerczuk, MD Robert P. Gilbert, MD Angel R. Gonzalez, MD Eduardo Gonzalez-Perez, MD Edmund G. Grant, Jr., MD Richard Gray, MD Daniel Guild, OD Annilea Gunn, MD, CCFP, FCFP A.R. Gutierrez, III, DO Ira Guttentag, MD, FACS Matthew T. Hartlage, MD David R. Heiman, MD Belen M. Herrero-Mujic, MD Joseph Hubaykah, MD Paul Hughes, MD, JD Allison Hull, DO Ronald “Tripp” Hulse, MD Richard J. Ina, MD, AAFP, ABFM Sajid Ismail, DO Imran Ismail, DO M. Gerard Jackson, MD, FACOG Jennifer Jain, MD Julio A. Gonzalez-Paoli, MD Somasekhara Kaipu, MD Kanchan N Kamath, MD Samir Kapoor, MD, FRCS Imran Kayani, MD Sohail Khan, MD Barkat U. Khan, MD Allauddin Khan, MD Tomas Korensky, MD Sujal Kotadia, MD Yuvraj Kumbkarni, MD Anjum Kumbkarni, MD, MBA Shana Laflin, MD Sean Lannon, MD Todd LaRue, MD Debra Lastarria, MD Nigel Lewis, MD Arlene D. Lobo, MD, FACC Jonathan C. Lohrbach, MD, FACS Edwin Lopez-Chaves, MD Roshan Mahtani, MD Martin Maldonado, MD, FACG Frederick M. Malibiran, DO Shifa H. Malik, MD Veronica Mardo, MD Carlos C. Marinelli, MD, FACC Morayma Martinez, MD Ajay Mathew, DO Earl W. McAllister, MD, FACS Richard F. McDonough, MD Tracy McKay, DO Roberto P. Medina, MD, FACC Luis A. Melendez-Collazo, MD Marian F. Menezes, MD, FCCP Naresh Menezes, MD Lakshmi Menezes, MD Andrew Messina, MD Lance R. Meyerson, MD, FACS Shashank Mishra, MD Michael Montuno, MD Anetha Moorthal, MD Reynaldo Mulingtapang, MD, FACC Daniel E. Murphy, MD Sameer H. Nagamia, MD Sami Nallamshetty, MD, FACAAI Charles “Chuck” Nalley, MD Florence Nappi, MD Phuong Nguyen, MD Marty W. Odom, MD Catherine Paltoo, MD Santo Paniello, MD, FACOG Kanchan Parasher, MD Vijay Patel, MD Pankaj Patel, MD Niraj Patel, MD, FACOG Mikin Patel, MD Manuel C. Sáinz de la Peña, MD Paul Phillips, DO Parag Pitroda, MD J. Kevin Poitras, MD Jesal V. Popat, MD, FACC Gilbert Postler, MD Ricardo Prieto, MD Allen Pusateri, MD Thomas Pusateri, MD Sivaram Rajan, MD Arnold M. Ramirez, MD Stephen Raterman, MD, FACS Daniel A. Reichmuth, MD, FAAAAI, FACAAI Samina Reza, MD David Rivera, MD Mayra M. Rivera, MD Michael "Giles" Roberts, DO Daniel Rodriguez, MD Ernesto Rodriguez-Velazquez, MD, RhMSUS Keith Alexander Rosenbach, MD, PhD Abhik Roy, MD Rene Santoscoy, MD Chandresh Saraiya, MD Vanessa Sarquis, MD Sam E. Scolaro, DO Jeffrey See, MD Sailesh N. Shah, DO, FCCP Chirag Shah, DO Sejal Shah, MD Shaily Shah, DO R. David Shepard, MD David Sikes, MD Soloman R. Singh, MD Frank A. Sirchia, MD Joel Sokolik, MD Gabriel J. Somori, MD Yamira Soto, MD James A. Sotrop, MD Christopher G. Spanich, MD Megan Spencer, MD Katherine Standley, DO Jason Stanton, MD Cicily Stanton, MD John Thompson Sullebarger, MD Brent C. Sullivan, MD Sravan Thangeda, MD Robert J. Theobald, III, DO Andrea Tordini, MD Amarilis Torres, MD Maulik K. Trivedi, MD Sonia D. V. Trzmielina, MD Petros Tsambiras, MD Jessica Valenti, MD Suresh Vemuri, MD Rohit K. Vyas, MD Ravikanth Vydyula, MD Stanley Watkins, MD Jennifer Wetherington, MD Jennifer White, MD Thomas W. Woodrow, MD, FACC Mark J. Yockey, MD James Zaccari, DO Alyssa Zwarych, MD Julie G. Lewerenz, Au.D. Sierra MacDonald, Au.D. Jennifer Miller, Au.D. Natalie Abell, PA-C Alexis Prickett Adams, PA-C Tina Agostinelli, PA-C Akosua Agyemang, APRN, DNP Crystal Alshamai, PA-C Kelli Anzalone, APRN Christina Arnold, PA-C Benise Artus, MS, APRN-C Xiomara Matias Ayala, APRN Erin Barowski, MSN, APRN, FNP-BC Sherdene Barrett, APRN James Bishop, PA-C Jennifer Boatwright, PA-C Boris Borissov, APRN Matthew Brice, PA-C Lindsey Broadnax, PA-C Stefanie Caggiano, APRN Robert Carr, PA-C Brandy Centers, APRN Lee Chatham, APRN Anne Clark, APRN-BC, MS Deborah Collura, MS, APRN-BC, MBA Stephanie Commet, APRN, MSN, AGACNP-BC Heidi Cook, APRN Selena Crandall, MSN, APRN Rachel Odioso Cruz, PA-C Marian Dam, DNP, APRN-BC, CDE Stephanie Delvaux, APRN Anne Dempsey, APRN-BC Dimple Desai, PA-C, MMSc, MT Sara Dominic, APRN-BC Nicole Donovan, PA-C Sarah Drapela, CNM, APRN Nadia Etienne, APRN Kyle Eury, MSN, APRN Sheena Eversole, APRN, MSN-FNP Benjamin Feldman, PA-C Luz Figueroa-Escalera, MSN, APRN Rebecca Fisher, PA-C Amanda Fitch Nagy, APRN Khristel Fonseca-Miller, APRN, NP-C Erica Franchick, PA-C Lisa Gavosto, APRN, NP-C Susan Gibbs, APRN Joshua Gilliam, PA-C, ATC Erin Godlewski, APRN-BC Alicia Grigsby, APRN-BC Ashley Gruber, MS, APRN, FNP-C, CMSRN Sarah L. Hamlin, APRN, MSN Stephanie Hampton, MSPAS, PA-C Mary Hanley, APRN April Hatfield, APRN Lisa Hayes, PA-C Tina Heinrich, MS, APRN Joan Heitzler, APRN, ANP-BC Amie Hellman, APRN Tamara Holmes, MSN, ARNP-C Jessica Hahn Hutchins, APRN Skyler Jacobs, CNM JonAnne Jameson, APRN Nan Jameson-Lee, APRN Meggan Jaramillo, CNM Debra Jeakle, APRN-CS Diana Cristina Jennings, MSN, APRN, FNP-C Marissa Johnson, MSN, APRN, FNP-BC Ashley Johnston, PA-C Jessica Kokich, APRN Rebecca Kraft, APRN Michele Laine, MSN, APRN-BC, CDE Erin Lange-Vandello, MS, PA-C Meghan LaRose, PA-C Beth Ann Leaf, PA-C Mextli Lermont-Ortiz, MPAS, PA-C Heather Leto, APRN, FNP-C Kelly Lidz, APRN, PMHNP-BC Cori Lloyd, APRN, DNP, WHNP-BC Brittany Loringer, PA-C Romainda Lubin, APRN-C John Paul Ludovice, APRN Glenn MacLean, PA-C Sasha Madden, APRN Danay Marante, MS, PA-C Meghan Maritato, APRN-BC Emily Martin, PA-C Julie Martinez, MSN, FNP-BC Maxx Ramirez, PA-C, MPAS Erin McDonough, APRN, DNP John McGowan, PA-C Brittany Mertz, PA-C Melissa Miranda-Luciano, APRN-C Neda Moghadasi, APRN-C, MSN Darlene Montani, MSN, APRN, FNP-BC, ONC BrettAshley Montero, APRN Diana Moorer, APRN, FNP-BC Rita Morgan, APRN-BC Nickeya Murphy DNP, APRN, FNP-C Brian Nagel, PA-C Melissa Nihiser, APRN, NP-C Tracey Nimeh, PA-C Julie Norton, APRN Caitlin M. Odom, PA-C Karen Olivero, MMS, PA-C Scarlette Owens, APRN-C, MSN Patricia Pamas, APRN, FNP-C Alise Pastorik, APRN, DHSc-BC, MS Bhumika Patel, PA-C Dee Perez, APRN Francine Phillips, MPAS, PA-C Cristina Relihan, PA-C Lauren Ruff, PA-C Cheryl Rumph, APRN, AGACNP-BC R. Scott Scheirer, APRN-BC, MSN Heather Schryver, APRN-BC Kjersti Sikes, APRN-BC, PMHNP-BC Jasmine Siska, PA-C Barbara Smith, APRN Shannon Smith, APRN Christina Stieber, PA-C Amanda Sturgeon, APRN, MSN, FNP-BC Stephanie Symonds, APRN, PMHNP-BC Laura J. Szydlowski, APRN-BC Sajedah Taher, DNP, APRN-BC Leah Terry, APRN, FNP-C Ratchadakon "Pat" Tran, MSN, APRN Joanie Turner, CNM, APRN Barbara Vargas, PA-C Brittany Villa, MS, APRN-C Julie Vining, APRN, NP-C Amber Vogt, APRN Erik Wells, APRN-BC Danielle Williamson, APRN, NP-C Lauren Yates, PA-C Nadia Zhylin, APRN, FNP-BC Allergy, Asthma & Immunology Ambulatory Surgery Centers Anesthesiology Audiology & Hearing Aids Cardiology Dermatology Diagnostic Laboratory Endocrinology Gastroenterology Hematology & Medical Oncology Hospital Medicine Infectious Diseases & Wound Care Infusion Services Interventional Pain Management Nephrology Neurology Non-Interventional Pain Management Nutrition & Diabetes Education Obstetrics, Gynecology & Midwifery Ophthalmology Optometry Orthopaedics, Sports Medicine & Spine Otolaryngology - Ear, Nose & Throat Palliative Care Pathology Pediatrics Pharmacy Physical Therapy Podiatry Primary Care Proctology Psychiatry & Behavioral Health Pulmonology & Sleep Disorders Radiology Rheumatology Spine Surgery Surgery Urgent Care Urology Vascular Surgery Well-Being Program
Date Range - Start
Date Format: MM slash DD slash YYYY
Date Range - End
Date Format: MM slash DD slash YYYY
I authorize Florida Medical Clinic, LLC to also share the following to the entity listed above. By not selecting any of the options below, I understand this information will not be shared. Other*
This authorization for release of information covers the period of healthcare services rendered from:* Date Range - Start*
Date Format: MM slash DD slash YYYY
Date Range - End*
Date Format: MM slash DD slash YYYY
Unless otherwise revoked, this authorization will expire on the following date, event, or condition. If no date is specified, I understand this authorization will expire one year from the date below.* Expiration Date*
Date Format: MM slash DD slash YYYY
I understand the information in my health record may include information relating to sexually transmitted disease and other reportable disease, AIDS/HIV. It may also include psychiatric or mental health services, and treatment for alcohol and drug abuse. By not selecting any of these options above, I understand sexually transmitted diseases, mental health, and drug abuse will not be disclosed.
I have the right to revoke this authorization at any time by contacting Florida Medical Clinic, LLC. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
I understand signing this authorization is voluntary. I do not need to sign this form in order to receive treatment.
I understand I may inspect or copy this information to be used or disclosed, as provided in CFR 164.524.
I understand that any disclosure of information carries with the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
I understand there is a fee for obtaining medical records and I agree to pay for such charges.
If I have any questions about disclosure of my health information I can contact Florida Medical Clinic’s Privacy Officer at (813)751-3603.
Electronic Signature*
Signature Date
Date Format: MM slash DD slash YYYY
Who was the last provider you saw? If the last provider you saw is not listed, please select "Other".* Select a Doctor Other Nathan Meyer, PharmD Mazen A. Abboud, DPM Sameer Ahmed, MD Sujani Akkineni, MD, HMDC Ambreen Alam, DO Kelsey Alcocer, OD Alejandro Cintas, MD “Trey” Gerald Alexander, III, MD Jeralyn A. Allen, MD Kathryn Anderson, MD C. Nancy Anise, MD Kimberly Apple, MD, FACS Hal J. Applebaum, MD, FACC Mark L. Arey, MD Douglas Baska, DO Colin S. Beach, MD Rafael Blasini, MD Michael Branch, MD Antonio Bunker-Huertas, MD Allison R. Burton, MD Richard Bymaster, MD Diana C. Calderone, MD William Capo, MD, FACC Joseph S. Caradonna, MD Carlos Cardenas, MD Rachel Careccia, MD Carrie A. Downey, DO S. Bill Carter, MD Alejandro Carvallo, MD, FACP Norman Castellano, MD Thomas Castillenti, DO Elvis Castillo-Garcia, MD, CWSP Juan Cevallos, MD Sirisha Chalasani, MD Tawfik Chami, MD George R. Cheeseman, III, MD Paul Citrin, MD, FACS Whalen Clark, MD, FACS Joseph S. Cody, MD Timothy J. Connor, MD Seth Cooper, MD Yamitza Cordero-Ferrer, MD, FACP, BS Leonard Cortelli, Jr., MD Joseph Cozzolino, MD, MBA Geoffrey Cronen, MD Vladimir Curkovic, MD, FACC Gerald V. Curley, DO Resham Datta, MD George R. Davis, DO Veronica C. Davis, DO Jacqui Dawson, DO, ACOFP Maria DeCastro, DO Beverly Deliz-Tirado, MD Manjul Derasari, MD, PA Vijay M. Desai, MD Lisa M. Diaz, DO, FAAD Marianne Diego-Wright, MD Jon DiPietro, MD Nathan M. Do, MD, FCCP Brian C. Domby, MD Emilio Dominguez, MD Theron A. Ebel, MD, FACP, FCCP Mark Eisner, MD Shweta Ekka, MD Lowella Esperanza, MD Anthony Esposito, DO Natalie Faith, MD, RhMSUS, RMSK Dennis H. Feldman, MD Alicia Fierro, DO Fabiola Figueroa, MBA, RD, CDE Astrid Figueroa, DO Tomas Figueroa-Nieves, MD Nancy Finnerty, MD, PhD Lucretia Fisher, MD, HMDC Hector L. Fontanet, MD, FACC Mitchell Forman, MD Barry Frank, MD Christopher Garcia, MD Roger “Casey” Gaskins, III, MD Paul Z. Gerczuk, MD Robert P. Gilbert, MD Angel R. Gonzalez, MD Eduardo Gonzalez-Perez, MD Edmund G. Grant, Jr., MD Richard Gray, MD Daniel Guild, OD Annilea Gunn, MD, CCFP, FCFP A.R. Gutierrez, III, DO Ira Guttentag, MD, FACS Matthew T. Hartlage, MD David R. Heiman, MD Belen M. Herrero-Mujic, MD Joseph Hubaykah, MD Paul Hughes, MD, JD Allison Hull, DO Ronald “Tripp” Hulse, MD Richard J. Ina, MD, AAFP, ABFM Sajid Ismail, DO Imran Ismail, DO M. Gerard Jackson, MD, FACOG Jennifer Jain, MD Julio A. Gonzalez-Paoli, MD Somasekhara Kaipu, MD Kanchan N Kamath, MD Samir Kapoor, MD, FRCS Imran Kayani, MD Sohail Khan, MD Barkat U. Khan, MD Allauddin Khan, MD Tomas Korensky, MD Sujal Kotadia, MD Yuvraj Kumbkarni, MD Anjum Kumbkarni, MD, MBA Shana Laflin, MD Sean Lannon, MD Todd LaRue, MD Debra Lastarria, MD Nigel Lewis, MD Arlene D. Lobo, MD, FACC Jonathan C. Lohrbach, MD, FACS Edwin Lopez-Chaves, MD Roshan Mahtani, MD Martin Maldonado, MD, FACG Frederick M. Malibiran, DO Shifa H. Malik, MD Veronica Mardo, MD Carlos C. Marinelli, MD, FACC Morayma Martinez, MD Ajay Mathew, DO Earl W. McAllister, MD, FACS Richard F. McDonough, MD Tracy McKay, DO Roberto P. Medina, MD, FACC Luis A. Melendez-Collazo, MD Marian F. Menezes, MD, FCCP Naresh Menezes, MD Lakshmi Menezes, MD Andrew Messina, MD Lance R. Meyerson, MD, FACS Shashank Mishra, MD Michael Montuno, MD Anetha Moorthal, MD Reynaldo Mulingtapang, MD, FACC Daniel E. Murphy, MD Sameer H. Nagamia, MD Sami Nallamshetty, MD, FACAAI Charles “Chuck” Nalley, MD Florence Nappi, MD Phuong Nguyen, MD Marty W. Odom, MD Catherine Paltoo, MD Santo Paniello, MD, FACOG Kanchan Parasher, MD Vijay Patel, MD Pankaj Patel, MD Niraj Patel, MD, FACOG Mikin Patel, MD Manuel C. Sáinz de la Peña, MD Paul Phillips, DO Parag Pitroda, MD J. Kevin Poitras, MD Jesal V. Popat, MD, FACC Gilbert Postler, MD Ricardo Prieto, MD Allen Pusateri, MD Thomas Pusateri, MD Sivaram Rajan, MD Arnold M. Ramirez, MD Stephen Raterman, MD, FACS Daniel A. Reichmuth, MD, FAAAAI, FACAAI Samina Reza, MD David Rivera, MD Mayra M. Rivera, MD Michael "Giles" Roberts, DO Daniel Rodriguez, MD Ernesto Rodriguez-Velazquez, MD, RhMSUS Keith Alexander Rosenbach, MD, PhD Abhik Roy, MD Rene Santoscoy, MD Chandresh Saraiya, MD Vanessa Sarquis, MD Sam E. Scolaro, DO Jeffrey See, MD Sailesh N. Shah, DO, FCCP Chirag Shah, DO Sejal Shah, MD Shaily Shah, DO R. David Shepard, MD David Sikes, MD Soloman R. Singh, MD Frank A. Sirchia, MD Joel Sokolik, MD Gabriel J. Somori, MD Yamira Soto, MD James A. Sotrop, MD Christopher G. Spanich, MD Megan Spencer, MD Katherine Standley, DO Jason Stanton, MD Cicily Stanton, MD John Thompson Sullebarger, MD Brent C. Sullivan, MD Sravan Thangeda, MD Robert J. Theobald, III, DO Andrea Tordini, MD Amarilis Torres, MD Maulik K. Trivedi, MD Sonia D. V. Trzmielina, MD Petros Tsambiras, MD Jessica Valenti, MD Suresh Vemuri, MD Rohit K. Vyas, MD Ravikanth Vydyula, MD Stanley Watkins, MD Jennifer Wetherington, MD Jennifer White, MD Thomas W. Woodrow, MD, FACC Mark J. Yockey, MD James Zaccari, DO Alyssa Zwarych, MD Julie G. Lewerenz, Au.D. Sierra MacDonald, Au.D. Jennifer Miller, Au.D. Natalie Abell, PA-C Alexis Prickett Adams, PA-C Tina Agostinelli, PA-C Akosua Agyemang, APRN, DNP Crystal Alshamai, PA-C Kelli Anzalone, APRN Christina Arnold, PA-C Benise Artus, MS, APRN-C Xiomara Matias Ayala, APRN Erin Barowski, MSN, APRN, FNP-BC Sherdene Barrett, APRN James Bishop, PA-C Jennifer Boatwright, PA-C Boris Borissov, APRN Matthew Brice, PA-C Lindsey Broadnax, PA-C Stefanie Caggiano, APRN Robert Carr, PA-C Brandy Centers, APRN Lee Chatham, APRN Anne Clark, APRN-BC, MS Deborah Collura, MS, APRN-BC, MBA Stephanie Commet, APRN, MSN, AGACNP-BC Heidi Cook, APRN Selena Crandall, MSN, APRN Rachel Odioso Cruz, PA-C Marian Dam, DNP, APRN-BC, CDE Stephanie Delvaux, APRN Anne Dempsey, APRN-BC Dimple Desai, PA-C, MMSc, MT Sara Dominic, APRN-BC Nicole Donovan, PA-C Sarah Drapela, CNM, APRN Nadia Etienne, APRN Kyle Eury, MSN, APRN Sheena Eversole, APRN, MSN-FNP Benjamin Feldman, PA-C Luz Figueroa-Escalera, MSN, APRN Rebecca Fisher, PA-C Amanda Fitch Nagy, APRN Khristel Fonseca-Miller, APRN, NP-C Erica Franchick, PA-C Lisa Gavosto, APRN, NP-C Susan Gibbs, APRN Joshua Gilliam, PA-C, ATC Erin Godlewski, APRN-BC Alicia Grigsby, APRN-BC Ashley Gruber, MS, APRN, FNP-C, CMSRN Sarah L. Hamlin, APRN, MSN Stephanie Hampton, MSPAS, PA-C Mary Hanley, APRN April Hatfield, APRN Lisa Hayes, PA-C Tina Heinrich, MS, APRN Joan Heitzler, APRN, ANP-BC Amie Hellman, APRN Tamara Holmes, MSN, ARNP-C Jessica Hahn Hutchins, APRN Skyler Jacobs, CNM JonAnne Jameson, APRN Nan Jameson-Lee, APRN Meggan Jaramillo, CNM Debra Jeakle, APRN-CS Diana Cristina Jennings, MSN, APRN, FNP-C Marissa Johnson, MSN, APRN, FNP-BC Ashley Johnston, PA-C Jessica Kokich, APRN Rebecca Kraft, APRN Michele Laine, MSN, APRN-BC, CDE Erin Lange-Vandello, MS, PA-C Meghan LaRose, PA-C Beth Ann Leaf, PA-C Mextli Lermont-Ortiz, MPAS, PA-C Heather Leto, APRN, FNP-C Kelly Lidz, APRN, PMHNP-BC Cori Lloyd, APRN, DNP, WHNP-BC Brittany Loringer, PA-C Romainda Lubin, APRN-C John Paul Ludovice, APRN Glenn MacLean, PA-C Sasha Madden, APRN Danay Marante, MS, PA-C Meghan Maritato, APRN-BC Emily Martin, PA-C Julie Martinez, MSN, FNP-BC Maxx Ramirez, PA-C, MPAS Erin McDonough, APRN, DNP John McGowan, PA-C Brittany Mertz, PA-C Melissa Miranda-Luciano, APRN-C Neda Moghadasi, APRN-C, MSN Darlene Montani, MSN, APRN, FNP-BC, ONC BrettAshley Montero, APRN Diana Moorer, APRN, FNP-BC Rita Morgan, APRN-BC Nickeya Murphy DNP, APRN, FNP-C Brian Nagel, PA-C Melissa Nihiser, APRN, NP-C Tracey Nimeh, PA-C Julie Norton, APRN Caitlin M. Odom, PA-C Karen Olivero, MMS, PA-C Scarlette Owens, APRN-C, MSN Patricia Pamas, APRN, FNP-C Alise Pastorik, APRN, DHSc-BC, MS Bhumika Patel, PA-C Dee Perez, APRN Francine Phillips, MPAS, PA-C Cristina Relihan, PA-C Lauren Ruff, PA-C Cheryl Rumph, APRN, AGACNP-BC R. Scott Scheirer, APRN-BC, MSN Heather Schryver, APRN-BC Kjersti Sikes, APRN-BC, PMHNP-BC Jasmine Siska, PA-C Barbara Smith, APRN Shannon Smith, APRN Christina Stieber, PA-C Amanda Sturgeon, APRN, MSN, FNP-BC Stephanie Symonds, APRN, PMHNP-BC Laura J. Szydlowski, APRN-BC Sajedah Taher, DNP, APRN-BC Leah Terry, APRN, FNP-C Ratchadakon "Pat" Tran, MSN, APRN Joanie Turner, CNM, APRN Barbara Vargas, PA-C Brittany Villa, MS, APRN-C Julie Vining, APRN, NP-C Amber Vogt, APRN Erik Wells, APRN-BC Danielle Williamson, APRN, NP-C Lauren Yates, PA-C Nadia Zhylin, APRN, FNP-BC
Provider's Name
Please provide the name of the last doctor you saw here if you did not see it in the dropdown above.
What is your Driver’s License Number?*
No License Form Completed & Signed By Employee Name*