Healthcare MRI Records

HEALTHCARE MRI RECORDS RELEASE & REQUEST

This form authorizes the release or request of magnetic resonance imaging (MRI) studies and associated reports and records. Complete all applicable sections. This authorization complies with applicable privacy laws and describes the scope, purpose, and duration of the release. By signing, the patient or personal representative authorizes the release as set forth below.

Patient Information

Date of Birth:    Gender:

Phone:    Alternate Phone:

Facility Releasing Records

Records Custodian Name:    Phone:

Recipient / Requesting Party

Phone or Fax:    Secure Email / Transfer ID:

Records Requested (MRI Specific)

Body Part / Procedure:

Study Date(s) From:   To:

MRI images (DICOM) on CD/DVD or secure electronic transfer
Radiology report and impression
Prior imaging comparison studies and reports
Relevant clinical notes, exam notes, and ordering information
Operative or procedure notes related to study

CD/DVD physical media
Paper copies of reports only
Secure electronic transfer (encrypted) to recipient
Other:

Continuity of care / treatment   Second opinion   Insurance / benefits   Legal matter
Other purpose:

Sensitive Information

Some records may contain information considered sensitive under law (for example, behavioral health, psychotherapy notes, substance use disorder treatment records, HIV-related information, genetic testing). I specifically authorize release of the following categories by initialing next to each item. Initials:

Mental health / psychiatric records:    Psychotherapy notes (if any):

Substance use disorder treatment records:    HIV/AIDS-related information:

Authorization, Fees, Duration & Revocation

I authorize the release of the MRI records described above to the recipient named in this form. I understand that information released pursuant to this authorization may include information created or received prior to the date of this authorization. I understand the recipient may re-disclose the information and it may no longer be protected by privacy law; however, the recipient is requested to maintain confidentiality.

I understand that a reasonable fee may be charged for copying, producing, and/or delivering records and that such fees will comply with applicable law. I further understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. To revoke, notify the releasing facility's records custodian in writing.

This authorization will expire on: . If no expiration date is provided, this authorization will expire one year from the date of signature.

Additional Instructions / Limitations

Acknowledgment

By signing below I acknowledge that I have read and understand this authorization; that I have had an opportunity to ask questions and that my questions, if any, have been answered. I acknowledge that signing is voluntary and that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization unless allowed by law.

If signed by a personal representative, describe authority to act for patient (for example, legal guardian, health care agent under advance directive, executor):

Sign Now