Patient Records Release Form

This authorizes New Standard Imaging to release x-ray, digital impressions, and other diagnostic records to the Requestor for purposes of providing the Requestor with New Standard Imaging’s diagnostic imaging records.
This authorization shall expire 30 days from the date this form is submitted.
By signing this request, you agree to the following:
I understand that I have the right to revoke this authorization, and I must do so in writing. I understand that any such revocation will not affect any actions taken by New Standard Imaging in reliance on this authorization before its revocation. I understand that the Requestor may be able to redisclose protected health information provided by New Standard Imaging, and that the protected health information will no longer be covered by the federal privacy regulations implementing the Health Insurance Portability and Accountability Act of 1996.

Patient's Name

First Name

Last Name

Patient's Date of Birth

YYYY

Patient's Email

Patient's Phone

(###)

###

####

Requestor's Information

First Name

Last Name

Date of Request

YYYY

Additional Information

I agree to terms listed above.

*State law requires this order be presented at the time of service.

Yes

Patient Records Release Form

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