Records Release Online Form | Lake Medical Imaging

REQUESTING RELEASE OF THE FOLLOWING IMAGES AND REPORTS

"*" indicates required fields

We participate in Nuance PowerShare for transmitting of images.

Date*

Patient Name*

First Last

Patient D.O.B.*

Patient Phone*

If you had a name change, what was your previous name?

Requesting release of the following images and reports:

Records requested

Mammogram and any breast - related COPIES OF REPORTS
Note to our valuable patient: If this is your first mammogram with us, prior mammograms are your best friend. Having a prior mammogram available for comparison at the time of your upcoming appointment could avoid further unnecessary breast imaging or breast biopsy.
*Please create DECOMPRESSED CD images
*Only send film images if you cannot DECOMPRESS CD images or if the original mammogram was performed on film.

Other

Specify Other

IMAGES AND REPORTS

Please send requested records to:*

LAKE MEDICAL IMAGING
801 East Dixie Ave, Suite 104
Leesburg, FL 34748
Phone: (352) 787-5858
Fax (352) 728-6074

I authorize the facility named below to release protected health information (PHI) as requested above:

Name of Facility:*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

The information will be used or disclosed for the following purpose: comparison and/or diagnostic evaluation.

This authorization remains effective for one year from the date signed.

Josh Floyd, Privacy/Compliance Officer

Lake Medical Imaging
801 East Dixie Avenue, Suite 104
Leesburg, FL 34748
(352) 787-5858

I am filling this out as:**

Patient

Personal Representative/Guardian

Patient Name*

Date*

Personal Rep resentative/Guardian Name*

Relationship*

Date*

I understand that checking this box constitutes a legal signature confirming I acknowledge and agree the information submitted on this form is true and accurate.*

Yes

Revised 12/06/2021

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