Release of Information Form

Records Release Authorization

This is an authorization for the release of medical records FROM an outside facility TO Imaging Specialists. Please fill out all fields.
Prior Facility Information
Prior Facility Name*
Please do not put Imaging Specialists as the prior facility. This is the name of the prior facility we are obtaining your priors from.
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Prior Facility Phone Number*
Patient Info
Patient Name- First, Middle, Last*

First NameMiddle NameLast Name
Maiden name (if applicable)

Maiden name
Patient Phone Number*
Last 4 of SSN*
Birth Date*

MonthDayYear
Exams Being Requested

Please select prior exams we will need to request for your upcoming appointment
All Breast-related Imaging (Breast MRI/Mammograms/Biopsies/Ultrasounds)MRICTUltrasoundOtherOther
I request that my protected health information (PHI) be disclosed to:

Recipient Name: Imaging Specialists

Address: 1241 Woodland Ave
City: Mount Pleasant
State: SC
Zip: 29464
Phone: 843-881-4020
Fax: 843-881-7515

I authorize the following PHI to be released from my medical record(s): Radiology imaging and report(s)

I understand that the information in my health record may include information relating to sexually transmitted disease (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of alcohol or drug abuse.

Purpose for requesting information: Continuation of Care

Disclosure Format: US Mail and/or Fax (healthcare provider only)

By signing this authorization form, I understand that:

I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Health Information Management Department. Revocation will not apply to information that has already been disclosed in response to this authorization.
Unless otherwise revoked, this authorization will expire in one years time from the date of initiation.
Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.
Any disclosure of information carries with it the potential for unauthorized disclosure and the information may not be protected by federal confidentiality rules.
I Agree
Signature

Imaging Specialists of Charleston requires that you certify this form by submitting an electronic signature. To certify this form, read the text below and provide an electronic signature (type your name) before you submit the form.

I certify that the information on this form is accurate and that I (or patient representative) am the person submitting the form.
Printed Name*
Patient 's Name OR Name of Patient's Authorized Representative
Signature*

Clear
Patient's Signature OR Patient's Authorized Representative Signature
Relationship to Patient
Please Specify Relationship to Patient, if Authorized Representative
Date*

MonthDayYear
Date
Should be Empty:

Records Release Authorization

Prior Facility Information

Patient Info

Exams Being Requested