Robert Roach
 
 
 DocuSign Envelope ID: 2EBB7621-EDFE-47BB-A 
 :6C3A2DDDA86 
 ASSOCIATES MD 
 MEDICAL GROUP 
 4780 SW 64th Ave 
 Davie, FL 33314 
 Mon-Fri 8:30am - 5:00pm 
 medicalrecords@associatesmd.com 
 PATIENT INFORMATION 
 Robert Roach 
 LAST NAME: 
 FIRST NAME: 
 BIRTHDATE: 22/01/88 
 7862538738 
 CELL PHONE: 
 PSC 2853, Box 6139
APO AP 65831 
 ADDRESS: 
 Miami 
 Florida 
 33166 
 CITY: 
 STATE: 
 ZIP CODE: 
 PATIENT RECORD RELEASE AND LETTER OF PROTECTION 
 | do hereby authorize Associates MD Medical Group to furnish my attorney as identified below with full report of any 
 medical records and charges pertaining to my treatment.
 settlement, judgment or verdict by which 1 may eventually recover said fee. 
 PLEASE CHECK ONE: 
 X 
 Motor Vehicle Accident 
 Slip and Fall 
 01/02/24 
 DATE OF ACCIDENT: 
 The Law office of Edersy Suarez, P.A 
 LAW FIRM: 
 Edersy Suarez 
 ATTORNEY NAME: 
 DocuSigned by: 
 PATIENT SIGNATURE: 
 Rher 
 DATE: 
 20/08/17 
 F83488BE1E2D4FB.
