This is an authorization for the release of medical records
Prior Facility Name
Prior Facility Fax #
Patient Last Name
Patient Middle Name
Patient First Name
Date of Birth
SSN (optional or last 4)
I request that my protected health information (PHI) be disclosed to:
Recipient Name: Imaging Specialists
Address: 1241 Woodland Ave
City: Mount Pleasant
I authorize the following PHI to be released from my medical record(s): Mammogram and Ultrasound Report(s) to include Radiology film/imaging studies.
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
Disclosure Format: US Mail and/or Fax (healthcare provider only)
By signing this authorization form, I understand that:
Imaging Specialists of Charleston requires that you certify this form by submitting an electronic signature. To certify this form, read the text below and provide an electronic signature (type your name) before you submit the form.
I certify that the information on this form is accurate and that I am the person submitting the form.
Enter the Above Text(*)