Request and Authorization to Copy or Release Health Information

Patient Name:

First Middle Last

Phone Number(Required)

Birth date:

Address:

Street Address City State / Province / Region ZIP / Postal Code

RECIPIENT AND PURPOSE:

Information is delivered to me , the patient.

If this health information is not being delivered to me, then deliver to:

Street Address

Name of Facility / Organization Street Address City State / Province / Region ZIP / Postal Code

Fax:

The purpose of this Disclosure:

For continuing medical care

For legal purposes

For personal use

For Social Security/Disability

Others

Please check the appropriate box:

CD Pick up - Name of person /Office picking up CD:

TITLE

Type of Imaging Needed

Date of Service

Date of Pick up

CD to be mailed (See Box "||" for additional info needed)

Untitled

CD to be sent via FED-Ex, UPS, Cert, Mail, (Etc.) ID Tracking #

Untitled

Send via Courier - Office / Physician name:

Electronic transmission to Patient / Physician Email:

Signature of Patient or Personal Representative(Required)

Date

*Name of Personal Representative (if applicable)

*The Name of Personal Representative (if applicable) is the patient’s decision maker. It can be the parent if the patient is a minor, legal guardian, health care surrogate, or other person.

Relationship to patient