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    Medical Imaging Record Release

    Uploaded by

    Darby Field
    The document is an authorization form for the release of protected health information and medical images from the Department of Radiology at Cambridge Health Alliance. It provides details about the patient, including name, date of birth, address and contact information. It specifies the types of exams and images to be released, to whom they are being released, and for what purpose (e.g. medical care, insurance, legal). The patient signs to authorize CHA to release the information as described and acknowledges they can withdraw authorization at any time.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Medical Imaging Record Release

    Uploaded by

    Darby Field
    37 views1 page
    The document is an authorization form for the release of protected health information and medical images from the Department of Radiology at Cambridge Health Alliance. It provides details about the patient, including name, date of birth, address and contact information. It specifies the types of exams and images to be released, to whom they are being released, and for what purpose (e.g. medical care, insurance, legal). The patient signs to authorize CHA to release the information as described and acknowledges they can withdraw authorization at any time.

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    The document is an authorization form for the release of protected health information and medical images from the Department of Radiology at Cambridge Health Alliance. It provides details about the patient, including name, date of birth, address and contact information. It specifies the types of exams and images to be released, to whom they are being released, and for what purpose (e.g. medical care, insurance, legal). The patient signs to authorize CHA to release the information as described and acknowledges they can withdraw authorization at any time.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    37 views1 page

    Medical Imaging Record Release

    Uploaded by

    Darby Field
    The document is an authorization form for the release of protected health information and medical images from the Department of Radiology at Cambridge Health Alliance. It provides details about the patient, including name, date of birth, address and contact information. It specifies the types of exams and images to be released, to whom they are being released, and for what purpose (e.g. medical care, insurance, legal). The patient signs to authorize CHA to release the information as described and acknowledges they can withdraw authorization at any time.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    AUTHORIZATION FOR RELEASE OF PROTECTED

    Department Of Radiology HEALTH INFORMATION (MEDICAL IMAGES)

    Medical Record # _________________________________ Date of Birth: __________________________

    Patient Name: ___________________________________________________________________________


    Last First Middle

    Home Address: __________________________________________________________________________

    City: _______________________________State: ________________________Zip: ___________________

    Telephone Contact #: Day: ( ) ____________________ Evening: ( )_____________________

    I, _________________________________do hereby authorize Cambridge Health Alliance (CHA), Department


    of Radiology to release the following medical images including imaging reports to the following persons at the
    locations or facilities listed below, for the purposes described:
     Medical Care  Insurance  Legal  Personal  Other _______________________
    INFORMATION TO BE RELEASED:
    Exam: ________________________________________________Date Performed:_____________________
    Exam: ________________________________________________Date Performed:_____________________
    Exam: ________________________________________________Date Performed:_____________________
    Other: _______________________________________________

    Release information to:


    Patient Patient representation: Name _________________________________ Other

    Name/Facility: ____________________________________________________________________________

    Attention to:________________________________________ Phone: _______________________________

    Address: _________________________________________________________________________________

    City: _______________________________________State: __________________ Zip: _________________

    I understand that:
    • I may withdraw my authorization at any time by submitting a written request to the Director of Radiology.
    Authorization may be withdrawn except for the following:
    - to the extent that action has been taken in reliance on this authorization.
    - if the authorization is obtained as a condition of obtaining insurance coverage, other laws provide the insurer
    with the right to contest a claim under the policy
    • Information released on this authorization, if redisclosed by the recipient, is no longer protected by CHA

    I have read and understand the terms of this Authorization and I have had the opportunity to ask questions
    about obtaining, using and disclosing my health information as listed above. By my signature below, I hereby
    knowingly and voluntarily authorize Cambridge Health Alliance to obtain, use and/or disclose my health
    information in the manner described above.

    Signature of Patient: __________________________________________ Date: ______________________

    When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal
    representative is required.

    Signature of Legal Representative: _________________________________________________________

    Print Name: __________________________________________________Date: ______________________

    Relationship of representative to patient: ______________________ __ Date: ______________________


    **Please bring this completed form to the Radiology dept of one of our CHA campuses in person with
    proper identification. For additional information, please call 617 665 1831**

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