Manuel Portalatin, MD
Patient Forms

Welcome to Baptist Primary Care. To help expedite your first visit, we provide our health forms online so that you can print and complete them at your convenience. If you have any questions, please don’t hesitate to contact our office staff.

Baptist Primary Care Forms:

BPC Authorization for Use of Answering Machines*

Authorizes Baptist Primary Care to leave appointment, referral and test results information on your answering machine.
BPC Health Care Status Authorization*

Authorizes Baptist Primary Care to release information concerning the status of your health care, including laboratory and radiology results and to discuss your treatment plan with an individual that you name.
Medical History*

Provides your primary care physician with important information about your medical and family history to better diagnose, treat or prevent conditions.
Medical Records Request or Release*

Initiates your request to have your medical records sent to another medical provider and/or to request your medical records from another provider be sent to your primary care doctor.
Health Care Authorization for Minors*

Authorizes Baptist Primary Care to deliver medical services and treatment to your children.
Results Authorization*

Authorizes Baptist Primary Care to make available test results and other office communication through the Medical Information Network.
BPC Patient Registration and Authorization*

Captures patient demographic information, insurance information and authorizes Baptist Primary Care to prepare and submit your medical bill directly to your insurance company.
Advance Directives - Overview*

This link opens the official Florida Agency for Health Care Administration website. It provides detailed information about advance directives, patient's rights, frequently asked questions and forms.
Advance Directives - Living Will Form*

This link opens the official living will form provided by the Florida Agency for Health Care Administration. This form allows you to document your instructions to your doctor to provide, withhold or withdraw life-prolonging procedures.
Advance Directives - Designation of Health Care Surrogate Form*

This link opens the official designation of health care surrogate form provided by the Florida Agency for Health Care Administration. This form allows you to designate another individual to make treatment decisions on your behalf.
Advance Directives - Uniform Donor Form*

This link opens the uniform donor form provided by the Florida Agency for Health Care Administration. This form allows you to indicate your desire to make an anatomical decision after death.
Advance Directives - Wallet Card*

This link opens the Advance Directives wallet card provided by the Florida Agency for Health Care Administration.

Requires Adobe® Acrobat Reader or Apple® Preview application. Click [ HERE ] to download and install the latest version of the Adobe® Acrobat Reader. Once you have the reader installed, you will be able to open and print the selected form.

Manuel Portalatin, MDPatient Forms

BPC Authorization for Use of Answering Machines*

BPC Health Care Status Authorization*

Medical History*

Medical Records Request or Release*

Health Care Authorization for Minors*

Results Authorization*

BPC Patient Registration and Authorization*

Advance Directives - Overview*

Advance Directives - Living Will Form*

Advance Directives - Designation of Health Care Surrogate Form*

Advance Directives - Uniform Donor Form*

Advance Directives - Wallet Card*

Related Pages

Baptist Primary Care

Services

Cosmetic Laser Surgery

NEW: Online doctor visits

Blood work

Bone density scans

Complete physicals

EKG (electrical activity of the heart)

Family planning

Immunizations

Lab testing

Pap testing

Minor surgeries

Nutritional counseling

School/athletic physicals

Smoking cessation

Well-child visits

X-rays

Phone Directory

Hours

Providers at this location:

Also at this location:

Belynda McCurry, PA-CRequest Appointment

Manuel Portalatin, MD
Patient Forms