Disclosure of Health Information

Disclosure of Health Information

This is a request for medical records to be sent FROM Imaging Specialists TO an outside facility.
Name*

First NameLast Name
Date of Birth (MM/DD/YYYY)*
Last 4 digits of Social Security Number
Facility Name to Release Records to*
*Please do not put Imaging Specialists of Charleston, this is for the facility name that we are releasing records to*
Facility Address to Release Records to*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Fax Number*
To ensure your provider gets reports, please provide the fax number to the facility receiving your records. Failure to do so, may cause a delay in them receiving reports
Exams to be Released
I authorize the following exams to be released from my medical record(s):*

All Breast-related Imaging (Mammogram/Breast MRI/Ultrasound/Biopsy)MammogramMRICTUltrasoundXrayOther
Type of records to be sent:*

IMAGES AND REPORTS (Images will either be mailed on a disc or electronically shared and the reports will be faxed to number you provided above)JUST REPORTS (Reports will be faxed to number you provided above)
Exam(s) covering the period of healthcare from (Specific Dates)*
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. The 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.
- 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 redisclosure, and the information may not be protected by federal confidentiality rules.
Printed Name*
Patient 's Name OR Name of Patient's Authorized Representative
Signature*

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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:

Disclosure of Health Information

Exams to be Released