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Radiology film request form

Presbyterian Medical Center Services Imaging Radiology film request form
First Name*
Last Name*
Birth Date*
Phone Number*
Email Address*
Date of Exam*
Date of Request*
Requested Films*
Do you want to*
Pick up location (*Required if Pick-Up or Both is selected.)
Physician Last Name (*Required if Send To Doctor is selected.)
Physician First Name (*Required if Send To Doctor is selected.)
Practice Name
Practice Phone Number (*Required if Send To Doctor is selected.)
Image format*
Notice:  This authorization is for full disclosure of Radiology records only.
Purpose of disclosure*
If you selected "Other", please explain (*Required if Other is selected.)
Restrictions:  I understand the recipient of the information may not use or disclose the medical information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by laws.
Release:  I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 90 days from the date of signature. I understand that I may cancel this request with written notification, but that it will not have any affect on information released prior to notification of Cancellation.
Type full name*
Additional Information
Questions:  If you have any questions regarding your exam, please contact the hospital where your exam was completed. If it is after 4:00 pm, during the weekend, or holiday, please call the Presbyterian Medical Center Radiology Film Room at 704-384-4040.