Release of Information Authorization

*Patient imaging reports are automatically faxed to the referring physician.

A

Patient imaging reports are automatically faxed to the referring physician.

APPOINTMENT DATE:

Patient name

Date of birth

If the patient would like a copy of their medical records but is unable or unwilling to pick-up the documents and wishes to authorize another individual to obtain the copies, the following must be completed:

Please note: The authorized individual will need to provide photo identification in order to pick up records on your behalf.

Name of authorized friend OR family member

Contact Number

I am aware I have the right to revoke this authorization at any time, provided that I give reason in writing. If I revoke this authorization, I understand Global Imaging will no longer use or disclose information with the authorized person stated above. I also understand, Global Imaging cannot retrieve any disclosures already made with my permission. (DISCLAIMER: Global Imaging adheres to the CMS HIPAA guidelines; Pursuant to Section 45 CFR 164.502(g))

I, the undersigned, have read the above and authorize the staff of Global Imaging to disclose such information as herein contained.

PATIENT or PARENT/GUARDIAN SIGNATURE

DATE

This authorization will expire 1 YEAR from the date of signing.

B

If the patient would like to send the report to another physician other than the referring physician, the following must be completed:

Alternate physician

Phone

Fax

C

I DO NOT authorize anyone to obtain my records other than myself and the referring physician.

PATIENT or PARENT/GUARDIAN SIGNATURE

DATE