Patient Forms
Thank you for selecting Intercoastal Medical Group to be your provider of health care services in Sarasota and Manatee Counties. It is our privilege to care for you and we strive to provide the best possible service. We look forward to a long relationship with you and your family.
If you are looking to download a new patient packet for a particular office, please choose from the listing below and click the "New Patient Form" link to download the form. To request medical records from a specific provider, choose from the list below, download the form, and submit to your doctor’s office.
NOTE: For physicians no longer with Intercoastal Medical Group, please fax your request to (941) 954-4440 or mail your request to Intercoastal Medical Group Corporate Office, 943 S. Beneva Road, Suite #306, Sarasota, FL 34232.
New Patient Forms
History and Physical
Medical Records Request:
- Steven Czak, DO, FACC
- Suzanne Lutton, MD, FACC, FACP
- Brett M. Milford, DO, FACC
- Antonio Moretta, MD
- Jovanna Morrison, ARNP-BC
- Hakim Morsli, MD, FACC
- Agam Patel, MD
- Mark Ramos, MD, FACC
- April Rubenstrunk, PA-C
- Anthony Skidmore, DO, FACC
- Ricardo Yaryura, MD, FACC
Nuclear Medicine, Stress Test & PET/CT Forms:
New Patient Forms
History and Physical
Medical Records Request:
New Patient Forms
History and Physical
Medical Records Request:
- Alexander Austin, MD
- Brittney M. Benjamin, MD
- Michael Bentze, DO
- Carrie N. Bonaroti, MD
- Felicia Canada, MD
- Josette Grice, MD
- Julia Havlovic, MD
- Anthony Hemmer, MD
- Amy Huber, PA-C
- Daniel Johnson, MD
- Pam Kelly, APRN, MS
- Chelsea Kidd, PA-C
- Joseph Larkin, Jr., MD
- Amanda Lindberg, MD
- Kevin Lipscomb, MD
- David G. Mohr, DO
- Dennis Pail, MD
- Randy Powell, MD
- Peter Quarles, MD
- Samuel Quartermaine, DO, Pharm D
- Sy Rabins, DO
- Diego Ramos-Rivera, MD
- Philip Rubin, MD
- Deborah Sauder, MD
- Anthony J. Spinella, MD
- John Steele, MD
- Alexander Thacker, MD
- Jessica Thomas, MD
New Patient Forms
History and Physical
Medical Records Request:
- Jeffrey Gretz, MD, PhD
- Kinan Rahal, MD
- Souvik Sarkar, MD, PhD
- Robert Summerlee, MD
- Michael P. Sassaris, MD (RETIRED)
Pre-Procedure Forms/Instructions:
New Patient Forms
History and Physical
Medical Records Request:
- Reinaldo Arroyo, MD
- Ryan R. Asterita, MD
- Charles Baten, MD
- Nataly Bruk, MD
- Joseph Creevy, MD
- David Daiello, MD
- Phyllis Elsishans, MD
- Jacob S. Gardner, MD
- Charles Hollen, MD
- Jessica Kassover, DO
- William Martin, MD
- Vicki McCarren, MD
- C. Ross Morrison, MD
- James Parker, MD
- David Reichel, MD
- Robert Alan Schwartz II, DO
- Arnoldo P. Singh, MD, PhD
- Mindy Ward, DO
Additional Forms
Additional forms and information you might find helpful:
- Medical Records Request (See above for specific offices)
- New Patient Form (Spanish, Española)
- Billing & Payments
- Notice of Privacy Practices
- Ambulatory Surgery Center Policies
- HIPAA Consent Form (English and Española)
- Notice of Privacy Practices Receipt
- Notice of Privacy Practices Receipt (Spanish, Española)
- Patient Financial Responsibility
- Patient Financial Responsibility (Spanish, Española)
- Patient Portal Consent
- History and Physical Form (Spanish, Espanola)
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.
