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MRI
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English
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Home
About Us
Our Services
MRI
MRA
Digital X-Ray
CAT Scan
DTI
Patients
Patient Registration Form
English
Spanish
Release of Information
English
Spanish
Insurance Plans
Accepted Forms of Payment
Appointment
Contact
Menu
Home
About Us
Our Services
MRI
MRA
Digital X-Ray
CAT Scan
DTI
Patients
Patient Registration Form
English
Spanish
Release of Information
English
Spanish
Insurance Plans
Accepted Forms of Payment
Appointment
Contact
RELEASE OF INFORMATION en
Release Of Information En
AUTHORIZATION TO USE & DISCLOSE PROTECTED HEALTH INFORMATION
Last Name
(Required)
MI
(Required)
First
(Required)
Date of Birth:
(Required)
MM slash DD slash YYYY
Patient Address:
(Required)
Patient Phone:
(Required)
Requestor’s Name:
(Required)
Requestor’s Address:
(Required)
Requestor’s Phone:
(Required)
Requestor’s Fax:
(Required)
THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL:
(Required)
MM slash DD slash YYYY
PURPOSE OF DISCLOSURE:
(Required)
Legal services
Processing of my insurance claim
Treatment in the facility indicated above
Application of insurance or state/federal funding programs
Other
I specifically authorize the use and/or disclosure of the following highly confidential information: Mental health, HIV results, AIDS information, sexually transmitted diseases, alcohol or drug abuse, sexual assault and/or child/adult abuse and/or neglect.
Signature
(Required)
SPECIFY INFORMATION TO BE DISCLOSED:
(Required)
History & Physical
Operative Report
Lab Reports
Pathology Report
X-ray Reports
MRI/CAT Scan Report and CD
Consultation Report
Other
I UNDERSTAND THAT:
List
I have the right to revoke this authorization for any reason and this revocation will not apply to information that has already been released in response to his/her authorization
Add
Remove
List
If I revoke this authorization, I must do so in writing and present my written revocation to the health information management department.
Add
Remove
List
I can refuse to sign this authorization.
Add
Remove
List
Any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.
Add
Remove
List
Authorizing the disclosure of my health information is voluntary.
Add
Remove
List
I understand that I may see and obtain a copy of the information described in this form, for a reasonable copy fee, if requested.
Add
Remove
I authorize Resolution Diagnostics Services or a member of its staff to discuss my health condition, plan of treatment, medical bills or other health information from my medical records with the individual listed below.
Name
(Required)
Phone
(Required)
I HAVE READ THE ABOVE AND AUTHORIZE THE DISCLOSURE OF THE PROTECTED HEALTH INFORMATION AS STATED:
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Print name of Patient/Guardian/Representative
(Required)
Relation of Patient
(Required)
