Public Records Request for Disciplinary Documents - Medical Quality Assurance - Public Records Request for Disciplinary Documents

Costs: (will be invoiced)	Duplication Charges (see Duplication Charges table)
	Written Certification of Documents - $25 fee in addition to duplication charges. You may complete the form and submit from your computer.

Certification Required (Additional Charge of $25.00) Certification NOT Required
Individual to be Researched:	First Name or Business Name: Middle Name or Initial: Last Name:
License Number:		Profession:
Document Type (all that apply)	Disciplinary Documents Disciplinary Final Order Other:
Additional identifying information (address, school, etc.) or special instructions to processor: Limit of 4 lines.

(Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.)

Documents are to be sent to:

Contact:		Phone Number:
Company:
Email:
Street Address:
City:
State:		Zip Code:

If you would like to take our optional survey please click the link: Public Records Request Survey