Visalia Imaging & Open MRI Physician Portal

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Please fill out and submit this form to request access. Allow 24-48 hours for a response by email. If you have any questions please contact Olivia at 559-734-5674 ext 103.

We strive to keep all of the information in your records correct and complete. If you identify any discrepancy in your records, you agree to notify us immediately by informing your provider. Additionally, by using the Referrer Portal the user agrees to provide factual and correct information.

By submitting this form you are agreeing to follow HIPAA compliance and Visalia Imaging reserves the right to approve, deny, or revoke access at any time.

First Name: *

Last Name: *

Company Name: *

What provider do you work for/with? *

Job title: *

If you have an NPI, please list it below.

Office Contact Number: *

Office Fax Number *

Office Address *

Work Email Address: *

Describe the patient information that you need to access and why? *

HIPAA Notice: I understand that I am being given access to protected patient information with the sole purpose of caring for the patient. I will not access any information that does not fall within the scope of my job duties and that is not necessary for patient care. Accessing information not needed to perform my job duties, accessing my personal, friends or family records and/or sharing my username/password is prohibited. All activity while logged in is monitored, any violations could lock you out of the system indefinitely. *

Yes, I have read and agree with the statement above.

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