FIBC Imaging Records Release. Authorization to use or disclose protected health information

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* Name

First

Last

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* Date of Birth

Please enter your date of birth

Date

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* Email (images will be sent to the email listed)

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* Verify Email

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* Address

Address

City/Town

State

ZIP/Postal Code

Country

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* Phone Number

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* Leave a Message

Yes

Imaging Records
Define your record request below

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* Dates of Treatment

Please enter the date of treatment

Date

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* If you are requesting records from multiple dates, please list them below.

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* Check All That Apply

Ultrasound

Mammogram

Dexa Scan

MRI

Nuclear Medicine

Biopsy

x-ray

Disc and Report Pickup

Other (specify below)

Other (please specify)

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* Ordering Provider

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* Purpose

Personal

Continuation of Care

Other (please specify)

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* REQUIRED Photo ID

Attach a copy (image) of your Photo ID Examples: driver's license, passport, state-issued ID card

PNG, JPG, JPEG file types only.

Choose File

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* RELEASE AUTHORIZATION
I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeﬁciency Syndrome (AIDS), Human Immunodeﬁciency Virus (HIV) and other communicable diseases, Behavioral Health Care/ Psychiatric Care, treatment of alcohol and/or drug abuse and genetic testing; my signature authorizes release of any such information.

I may refuse to sign this authorization form. I understand that Foundation Health Partners will not condition or deny treatment on my signing this authorization. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Foundation Health Partners’ Notice of Privacy Practices explains the process for revocation, which includes a request in writing.

Unless I revoke this authorization earlier, it will expire 6 months from the date signed.

I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be re-disclosed by the person or organization that receives the information.

I release Foundation Health Partners, its employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.

Typing my full name and date in the boxes below serves as my signature and authorization to release my information.

Signature of patient or legal representative:

Full Name of Requester

Today's date

Relationship to Patient

FIBC Imaging Records Release. Authorization to use or disclose protected health information

Question Title

* Name

Question Title

* Date of Birth

Question Title

* Email (images will be sent to the email listed)

Question Title

* Verify Email

Question Title

* Address

Question Title

* Phone Number

Question Title

* Leave a Message

Question Title

* Dates of Treatment

Question Title

* If you are requesting records from multiple dates, please list them below.

Question Title

* Check All That Apply

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* Ordering Provider

Question Title

* Purpose

Question Title

* **REQUIRED** Photo ID

Question Title

* REQUIRED Photo ID