Medical Records Release Form

MEDICAL RECORD RELEASE FORM FILM & REPORT I hereby authorize Imaging Associates of Canton to release my medical records as detailed below. The facility, its employees, officers and staff are released from legal responsibility or liability related to the release of this information to the extent indicated and authorized herein.
Patient Name:
Date of Birth:
Patient Address:
City:
State:
Zip:
Patient Phone Number:
Date of Request:

Information Requested
Date of Service:
Type of Study:

Information to be released to
Name:
Address:
City:
State:
Zip:
Phone:

*We will not be responsible for sending the requested records if any* of the above information is missing or incorrect.**
Electronic Signature: By typing your name you agree to have signed this document electronically.
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