Medical Records Release - Association Of Alexandria Radiologists
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1AUTHORIZATION TO DISCLOSE HEALTH INFORMATION –
MEDICAL RECORDS RELEASE
ALEXANDRIA IMAGING CENTER
WOODBRIDGE IMAGING CENTER
4660 Kenmore Avenue, Suite 525
4001 Prince William Parkway, Suite 302
Alexandria, VA 22304
Woodbridge, VA 22193
P 703.751.5055
P 703. 494.3309
F 703.370.3889
F 703.357.9636
Patient Name: _____________________________________________________________ Date of Birth: ______________ ____ _ ___
LAST
FIRST
MIDDLE
Address: _________________________________________________________________________________________________ _ ___
NUMBER & STREET
CITY
ZIP
Phone Numbers
________________________________________ _
_______________________________ _ ________ __ _
(Home)
(Cell)
If you have medical records at another facility that Association of Alexandria Radiologists, LLC needs to obtain please
fill out and sign below:
I hereby authorize the release of my medical records to the facility listed checked above from:
Facility ________________________________________ _ Phone _________________________ Fax _________________________
All imaged data and reports
Specific study(ies)
Permanent release of mammography
If you would like us to release or disclose your results and/or imaging studies and reports to a
third party release, another facility, or a family member please fill out and sign below:
I further authorize the disclosure of my radiology medical records from any Association of Alexandria Radiologists, LLC to
the following 3rd party individual(s)::
Name: _____________________________________________________________ Relationship:
Spouse
Child
Other
Address: _________________________________________________________________________________________________ _ ___
NUMBER & STREET
CITY
ZIP
Phone Numbers
________________________________________ _
_______________________________ _ ________ __ _
(Home)
(Cell)
Film/CD (1) Study _________________________ Date _________/(2) Study _________________________ Date ________ __
Report (1) Study __________________________ Date _________/(2) Study _________________________ Date _________
Other ________________________________________ Date __________________________
Released to: ____________________________________________________ Date _________________
This authorization can be revoked at any time with written notification. This authorization expires one year from the date signed.
_________________________________________________________________________ ________ Date:______________ __________
PATIENT (OR GUARDIAN) SIGNATURE
If not signed by the patient, please indicate the relationship: Proof of identity required.
Parent/Guardian
Beneficiary/personal representative of deceased patient
Guardian/conservator of an incompetent patient
Please note, there is no charge for the first CD copy. Additional CD copies are available for a fee of $7.00. Copies of films,
if available are $7.00/sheet.
FOR OFFICE USE ONLY Date Request Taken _____________ By ___________________ Date Picked Up _____________ By ___________________
Date Mailed Out _______________ By ___________________
# of Films Signed Out _______________ Identification Presented __________________
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