Patient Forms

Patient Forms

To expedite your appointment wait time, please print and fill out these patient forms and bring them with you at the time of your appointment.

 

Authorization for Medical Services Form

[English]
[Spanish]

PHI Disclosure Authorization Form and Acknowledgment of Receipt of Notice of Privacy Practice

[English]
[Spanish]


Medical Record Request – Release Form

  • Complete form with signature.
  • For the most prompt results, fax the completed form to facility where imaging was performed.
  • Bring form with any images you obtained to your Radiology Regional appointment.

     

  • You may also release Radiology Regional images with this form.

 

Medical Record Request-Release

[English]

[Spanish]

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Other Documents

Notice of Privacy Practices (for your records only)

[English]
[Spanish]