MEDICAL IMAGING MANHATfAN. LLC Medical Record Release/Request FormEffective Date: January 2, 2015

PATIENTINFORMATIONPatient Name

Home Phone #Date of Birth

AddressEmail Cell Phone #TYPEOFMEDICALRECORDREQUESTED- Check all that apply and list exam dates or date range.

oMammogram 0 Sonogram o Bone Densitometry 0 OtherOMRI

Our standard isto supplyyour digital imageson radiographicfilm. Pleasenotify us if your doctor requeststheseimageson disk, insteadof film, to avoid additional fee - Checkoff applicable: 0 Films 0 CD(DICOMFormat)PURPOSEOFMEDICALRECORDREQUEST- Check all that apply

If "Yes" please check the reasons that applyo Medical Insurance 0 Financial Difficulties oMoving o Other

Are you leaving Medical Imaging of Manhattan? YES0 NO

If "No" please check the reasons that applyo Appointment with a breast surgeon or oncologist When? _o For my own records 0OtherYour record request maytake 3-5 businessdaysto complete, unlessotherwise arranged. The processof printingyour recordswill not beginuntil written authorization is receivedand anyapplicable payment is received.AUTHORIZATION

I understandthis authorization shall becomeeffective immediately and shall remain in effect until three months from thdate of signature,or until I revoke it in writing, whichever occursfirst. I understand that information usedor disclosedpursuant to this authorization may be subject to re-disclosureby the recipient andmay no longer be protected by law.Additionally, I understandthat authorizing another personto pickup my recordscan include disclosureof servicesrendered, insurancepaymentsand/or denials,all demographic information, which can include date of birth, policynumber, homeaddress,telephone number, employer, and any other private information on my behalf.I authorizethe abovenamed ImagingCenterto releasemedical recordsand information pertaining to diagnosticreports and/or imagesfor the above namedpatient.Signature of person requesting records Date -1

If submitted by mail, email or fax, patient signature was compared to signature on file YESD NO 0* If Authorized Representative,relationship to patient -------------------------1* Legalauthority to accessthese recordswasverified byviewing

10VERIFICATIONOFPERSONPICKINGUPOR INTERPRETINGMEDICALRECORDSPatient / Authorized Representative IDENTIFICATIONwas verified by viewing photo ID YES0 NO 0

____________________________ Date _,

Medical records prepared and verified by (employee signature) _,Medical records red and released nature)

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rMEDICALIMAGING .MANHATIAN. LLC Medical Record Release/Request Form

Effective Date: January 2, 2015

OPTIONS FOR OBTAINING MEDICAL RECORDS- Please choose one

D Pick up at the office (We will notify you when your records are ready.)

D Deliver records to the below addressName / Facility Phone #Address Apt#City Zip** Note: There is NO CHARGE for the FIRST request of images from a specific date of service. If you wish trobtain a SECOND copy of the SAME images now or in the future, there is a $50 charge per date of service,if duplicates are on films. There is a $25.00 flat fee if the requested duplicates are on CD {Dicom Format}.Charges for Additional Sets of Images on Film 1$50.00 fee per additional set{s} x =$Charges for Additional Sets of Images on CD 1$25.00 fee (2eradditional set{s} x =$DELIVERY OPTIONS

Check oneManhattan Only (Messenger Service) $12.00 Fee for standard delivery (next day) D

$23.45 Rush fee (same day delivery) nOut of Area Delivery (UPS) $17.00 Fee for standary delivery (2-3 days) D

$27.00 Rush fee (next day delivery) IIL...J

*** Payment must accompany this form if records are being delivered or for duplicate requests ***METHODS OF PAYMENT

Signature

VISA ASTERCARD AMEX

Credit Card Number_I_Exp Date

*** INCOMPLETE FORMS WILL NOT BE PROCESSED ***

MESSENGER- Choose one D STANDARD RUSHDate Sent/Ready

UPS - Choose one D STANDARD RUSHPATIENT PICK UP IN OFFICE

Patient Name: _ MRN# ~

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