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. Please allow us 24 hours to complete the request.
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. If a phone number is put in place, your facility will not receive reports.
Exam(s) covering the period of healthcare from (Specific Dates)*
Exams to be Released
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)
I authorize the following exams to be released from my medical record(s):*

All Breast-related Imaging (Mammogram/Breast MRI/Ultrasound/Biopsy)MammogramMRICTUltrasoundXrayOther
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
Signature*

Clear
Patient's Signature OR Patient's Authorized Representative Signature
Date*

MonthDayYear
Date
Printed Name*
Patient 's Name OR Name of Patient's Authorized Representative
Relationship to Patient
Please Specify Relationship to Patient, if Authorized Representative
Should be Empty:

Disclosure of Health Information

Exams to be Released