3/10/23, 2:52 AM

REQ- Requestor
Madalon Law
Provider
Radiology
14725862 Contact: Associates of
Status Joseph Hollywood,
New Madalon Inc.
100 N Federal Attention:
Hwy, Suite CU- Memorial West
5 1 Zotec Way
Fort Carmel, IN
Lauderdale, FL 46032
33301
Phone: (954)
923-0072
Fax: (954) 923-
0074

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review. This is not an invoice. Please do not send payment at this
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Created Est. Fulfilled Purchased

ShippedMessage
3/9/2023 Completion Reported Forward
6:46
PM

Demographics Request Details Comments

First Jesse RecordBilling (No Requestor Please
Last Muniz Type Affidavit) Note send all
3/9/2023 the bills of
DOB 10/04/1998 6:46 PM the above
From
SSN ***-**-4741 client as
Scope provided
soon as
date range possible
Start as we
01/01/2023 need to
Date
End close the
03/09/2023 case.
Date
Requestor Please
Note send all
3/9/2023 the bills of
6:51 PM the above
Services client as
This is not an Invoice, soon as
do not send payment at possible
this time as we

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 3/10/23, 2:52 AM

Instant $22.00 need to

Download close the
case.
Custodian $0.00 Thank
Fee you.
Requestor Please
Total $22.00 Note send all
3/9/2023 the bills of
6:51 PM the above
client as
soon as
Documents and Records possible
as we
need to
Download
Size Last Viewed close the
Name Type Date
(KB) By (On) Selected case.
Thank
HIPAARadiolog Signe 03/0 249 View you.
yAssociatesofH d 9/20
ollywoodInc.pdf Author 23
ization
Form

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