Patient Authorization: Record Request / Release Form
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1Patient Authorization: Record Request / Release Form
FORM.POL.002
Effective Date: September 26, 2013
Imaging Center:
Date:
Patient Name:
DOB:
MRN Number:
Phone:
TYPE OF RECORD REQUESTED - Check all that apply
Report
Original Films
Copies of Films
Digital Prints
Images on CD
DELIVERY METHOD
MODALITY
Records to be Picked Up
MRI
Mammography
X-ray
Records to be Mailed / eMailed
CT
Ultrasound
Dexa
Records to be sent Certified Mail
PET/CT
Nuclear Medicine
PURPOSE OF RECORD REQUEST / RELEASE – Check all that apply
Dr. Appointment
Patient to Keep
Moved out of state
Biopsy
Comparison
Legal
Surgery
Other:
Dr. or Facility Reviewing Films:
I understand that this authorization shall become effective immediately and shall remain in effect until three
months from the date of signature, or until I revoke it, in writing, whichever occurs first. Additionally, I understand
that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may
no longer be protected by law. I understand and accept the statements contained in this authorization.
TO REQUEST MEDICAL RECORDS FROM ANOTHER FACILITY
_________________________________________________.
To:
I hereby authorize and request you to release to
__________________________________
Imaging Center the __________________________________________
(Type of Records / Body Part)
records in your possession concerning my treatment on/or between date(s): ___________________________________.
Patient Signature
Date
TO RELEASE MEDICAL RECORDS FROM A RADNET CENTER
I,
, hereby authorize, the above named RadNet Management Inc. Center, to
release medical records and information pertaining to diagnostic reports, images, and/or film for the above named
patient. I also agree to pay any fee associated with copying, reviewing and mailing the above records/images as follows:
Applicable Fees:
Delivered directly to another medical facility: No Fee - clerical / copying / delivery
Delivered to patient or non-provider third party: 1
st
nd
copy is free, 2
request $20.00 per sheet/CD
Delivery: Mailing cost fees as applicable
eMail Delivery (records only): eMail Address ____________________________________________________
Patient Signature
Date
F
M
O
:
OR
AMMOGRAPHY
NLY
I request that these O
F
and R
be released for:
Permanent Transfer
30 days
RIGINAL
ILMS
EPORTS
PATIENT AUTHORIZATION FOR PICK UP
ID VERIFICATION
____________________________________
I,
grant permission to release my
M
!
ANDATORY
:___________________________________.
records to
(Person picking up records)
I understand this will/can include discussing services rendered, insurance
Patient / Authorized Designee
payments, and/or denials, all demographic information which can include date of
IDENTIFICATION was verified by
birth, policy number, home address, telephone number, employer and any other
viewing and copy/scanning photo ID
private information on my behalf.
Signature of person picking up records:
If signed by other than patient, indicate relationship:
Witness:
Date:
Time:
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Parent category: Legal