Authorization for the Release of Medical Images
Please allow 72 hours to complete.                                                                                                                                
This form is for imaging requests only.                                                                                                                            The reports are send to the referring providers.                                                                                                              We can supply with a copy in the office.
Email *
Patient Frist Name *
Patient Last Name *
Patient Date Of Birth *
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Date Range of Service to be Released *
Please check specific information to be released: *
Required
A copy of your responses will be emailed to the address you provided.
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