RECORD RELEASE AND AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

I authorize Inland Imaging, LLC to release the specied protected health information described below:

Information to be released:

Radiology Report

Images

Report and Images

How would you like your images?

Flash Drive

Patient Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Exams Requested

Exam Date

YYYY

Exams Requested 2

Exam Date 2

YYYY

Exams Requested 3

Exam Date 3

YYYY

To be disclosed or released to:

Patient

Other

Please mail to:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I would like to pick up at:

This authorization expires on:

YYYY

Type your signature

By typing your name here you agree that your electronic signature is the legal equivalent of your written signature on this authorization. You will be called to verify your identity within 72 hours.