Mammography Requirements

There are a few things we are going to need before we can complete the process for your Mammogram.

1. Please complete the "Required Clinical Information for Mammography" and bring this paperwork with you.
2. Please complete the "Consent for Mammography for Patients with Implants." (This however only applies if you do have implants Please disregard if this does not apply to you.) If this form applies please bring this form with you.
3. We are going to any previous Mammogram films and reports you have had. We must have them before your first Mammogram at Midland Womens Clinic. They will need to be on a disc format not the actual films. There is a request for medical records and fax form attached for your convenience. Please complete the form in its entirety and fax it to the facility you had your Mammograms done at. If necessary you may need to pick those records up and bring them with you. The facility has 30 days to send the records. 

Most common fax numbers of surrounding facilities

Allison Womens Imaging
Fax: 432-221-4670 Attention: Medical Records

Odessa Regional Medical Center
Fax: 432-582-8945 Attention: Medical Records

Odessa Medical Center
Fax: 432-640-4218 Attention: Medical Records

You are here to have a mammogram, an x-ray examination of your breast(s). We understand that you have a breast prosthesis or implant. The presence of that implant may obscure some of your breast tissue, which can interfere with the detection of some forms of breast cancer. There is a remote possibility that the compression and manipulation used to perform this study could damage or rupture your implant(s). If you have any questions regarding these or any aspects of mammography, please ask the technologist prior to signing this form.

I have read the information contained in this form and have been advised of the risks involved in receiving a mammogram.

I consent to the performance of a mammogram study.

Comments:

Please send all films and reports for my Mammograms as soon as possible. If necessary please inform me and I will come pick them up.

CONFIDENTIALITY NOTICE: The document accompanying this facsimile transmission contains confidential information belonging to the sender that is legally privileged, and not intended for public use. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this tele-copied information is strictly prohibited. If you received this document in error, please notify us by telephone immediately.

Facility: Midland Women's Clinic
Address: 2500 W Illinois Ave Ste 100
State: TX Zip: 79701
City: Midland
Phone:432-699-2370 Fax: 432-697-3524

By signing this form, I authorize you to use and disclose the protected health information described below:

I understand:

• I may revoke this authorization at any time by sending a written notification to the Privacy Officer at the above address. Unless revoked, the expiration date will be one year from the date of my signature.
• I release the entities listed above, their agents, and employees from any liability in connection with the use of disclosure of the protected health information covered by this authorization. The entity authorized to disclose the information will not be compensated by the recipient for  the disclosure, except for the cost of copying and mailing as authorized by law.
• Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.
• I have the right to Inspect the health information to be released and I may refuse to sign this authorization. 
• Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of treatment or payment for my care on my signing this authorization.

I understand that my medical information may indicate that I have a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, Chlamydia, or the human immunodeficiency virus, also known as HIV. I further understand that my medical information may indicate that I am or have been treated for psychological or psychiatric conditions of substance abuse.

NOTICE OF RIGHTS: Information in your medical record that have or may have a communicable or venereal disease is made confidential by law and cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposure, disclosure pursuant to an order of the court of the Department of Health, disclosure among healthcare providers or disclosure for statistical or epidemiological purposes. When such information is disclosed it cannot contain information from which you could de identified unless disclosure of that identifying information is authorized by you, by and order of court of the court of the Department of Health or by law.

 

***MEDICAL RECORDS REQUEST FOR MORE THAN 3 YEARS WILL BE A $25 CHARGE***