Tampa Cardiovascular Associates, P.A.
Asad Sawar, M.D., F.A.C.C., Victor Feliz, M.D., F.A.C.C.
Hadi Mahmaljy, M.D., Alaa Boulad, M.D., F.A.C.C.
4450 E Fletcher Avenue, Suite C, Tampa, Florida 33613
Phone: (813) 975-2800, Fax: (813) 977-7924
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Patient's Name
DOB:
Social Security #:
A) REQUEST FOR RECORDS TO BE SENT TO TAMPA CARDIOVASCULAR ASSOCIATES:
I hereby authorize
To disclose my Protected Health Information to: Tampa Cardiovascular Associates
Fax: 813-977-7924
B) REQUEST FOR TAMPA CARDIOVASCULAR ASSOCIATES TO SEND RECORDS:
I hereby authorize Tampa Cardiovascular Associates to disclose my Protected Health information to the following organization and/or person:
Name:
Address:
Phone:
Fax:
I understand that I have a right to revoke this authorization at any time. I am aware that my revocation is not
effective to the extent that the persons I have authorized to use and/or disclose my Protected Health
Information have acted in reliance upon this authorization. I agree that a copy or fax of this release shall be
as valid as this original release. I authorize Tampa Cardiovascular Associates to fax the information. I realize
there are inherent risks in faxing Protected Health Information.
This authorization expires on
Signature of Patient or Patient's Representative
Date
Printed Name
Relationship to Patient
updated 7/1/25