Medical Release/Request

"*" indicates required fields

PATIENT INFORMATION:

Name:*

Date of Birth:*

Phone:*

RECORDS TO BE RELEASED:

Exam Needs:*

Images

Reports

Exam Name:*

Date of Service

INFORMATION REQUESTED FROM:

PREMIER MOUNTAIN IMAGING CENTER*

PREMIER MOUNTAIN IMAGING CENTER

RELEASE INFORMATION TO:

PATIENT

Name:

Deliver Via:*

E-Mail

Fax

Mail (address)

Pick-Up

Email:*

Fax:*

Mailing Address:*

Pickup Date:*

Pickup Time:

PERMISSION:

I, (Patient Name)*

hereby grant permission for you to release confidential health information about me, by releasing a copy of my medical record or a summary, or narrative of my protected health information to the physician, person, facility, or entity.

Signature*

Date:*

Premier Mountain Imaging Center

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