1075 Town Center Drive
    Orange City, FL 32763
    Phone (386) 917 – 0333
    Fax (386) 917 – 0335

    749 Stirling Center Place
    Lake Mary, FL 32746
    Phone (407) 321 – 8230
    Fax (407) 321 – 0388

    Paul Travis Smith, M.D. – Edward Kevin Scanlon, M.D. – Radhika M. Verma, M.D. –
    Kurt H. Bowman, M.D. – Ashraf Luqman, M.D. – Kristal A.Carthan, M.D. –
    Arianne Bennett, M.D. – Shahana Masood, MD
    Tara Monette, ARNP-C – Erin Ziegle, APRN – Justin Pickens, APRN

    AUTHORIZATION TO RELEASE MEDICAL RECORDS

    I hereby authorize Pulmonary Practice Associates to release medical records on the patient name above to

    (Doctor/hospital name)

    (Telephone number and address of Doctor, Hospital, etc)

    1075 Town Center Drive
    Orange City, FL 32763
    Fax (386) 917 – 0335

    749 Stirling Center Place
    Lake Mary, FL 32746
    Fax (407) 321 – 0388

    8400 Red Bug Lake Road
    Suite 210
    Oviedo, FL 32765
    Fax: 407-321-0388

    This request and authorization applies to (check all that apply):

    Pulmonary Function Test(s)Consultation(s)Last office noteRadiology Report(s)Pet ScanChest CTChest X-rayEchocardiogram(s)Laboratory(s)Sleep Study(s)Cardiac Catherization (RHC + LHC)Other

    THIS AUTHORIZATION EXPIRES AFTER ONE YEAR FROM THE DATE OF THE PATIENT OR REPRESENTATIVE SIGNATURE

    ABOUT US

    When it comes to breathing disorders, our physicians and staff at Pulmonary Practice Associates understand how important it is for you to choose a qualified physician who will provide the best care possible to get you back to living a healthy and comfortable life.


    1075 Town Center Dr, Orange City, FL 32763
    Phone Number: (386) 917-0333
    Fax Number: (386) 917-0335

    749 Stirling Center Place, Lake Mary, FL 32746
    Phone Number: (407) 321-8230
    Fax Number: (407) 321-0388

    8400 Red Bug Lake Road, Suite 2010, Oviedo, FL, 32765
    Phone Number: (407) 321-8230
    Fax Number: (407) 321-0388

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