Authorized Release of Medical Records

Authorized Release of Medical Records
Patient Name*

First NameLast Name
Date of Birth*
Exam Requested*
Body Part / Region*
Date of Scan*

MonthDayYear
Date
Recipient Name*
Facility Name
use this if a physician is the recipient
Recipient Phone*
Records Being Requested*

ImagesRadiology Report
Radiology Report Method of Release*

EmailFax
Recipient Email*
Recipient Fax*
Images Method of Release*

Mailing Address*In-Person Pickup
*A $15 fee may be incurred for discs that need to be mailed. Patients are encouraged to utilize the in-person pick up for ease of obtaining their records at no charge.

Fees may be waived if the recipient facility has a FedEx account number that can be used for this request.
Recipient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Pickup*

MonthDayYear
Date
I hereby authorize The Imaging Center of Grand Rapids to release the above records to the listed recipient(s). I understand that there is potential for information disclosed under the terms of this authorization to be re-disclosed by the recipient and no longer protected by 45 CFR Part 164, Subpart E of the Code of Federal Regulations. I understand that The Imaging Center is not liable for any use or misuse of these records once they leave the facility. Understanding the risks, I give my authorization freely and voluntarily. I understand that refusal to sign this document will not impact my treatment, payment, enrollment, or eligibility of benefits.
Signature of Person Completing Form*

Clear
Printed Name of Person Completing Form*

First NameLast Name
Relationship to Patient*
Email of Person Completing Form*
Should be Empty: