Authorization to Release PHI to WIA

Patient's name*

First NameMiddle Name (Optional)Last Name

Daytime phone*

Area CodePhone Number

I authorize the following facility to release the above named individual's Protected Health Information (PHI) specified below to Weinstein Imaging Associates.

Facility name*

Please provide an address, phone number, or FAX number for this facility so that we can contact them more easily.

Facility's address

Facility's phone number

Facility's FAX number

Types of PHI to be released*

Mammogram images and reportsSonogram/ultrasound images and reportsDXA (bone densitometry) images and reportsX-ray images and reportsMRI images and reportsPathology results of recent surgery/biopsyFollow-up information and/or recommendationsEntire medical record

Dates of mammograms

Dates of sonograms

Dates of DXA scans

Dates of X-ray studies

Dates of MRI studies

Is this a permanent transfer of PHI?*

YesNo

I authorize release of this information to Weinstein Imaging Associates, at the following location*

5850 Centre Ave, Pittsburgh, PA 15206, 412.441.1161, fax 412.441.98801910 Cochran Rd, #740, Pittsburgh, PA 15220, 412.440.6999, fax 412.440.69985500 Corporate Dr, #100, Pittsburgh, PA 15237, 412.630.2649, fax 412.630.2676

I understand that I have the right to revoke this authorization at any time, and that I must put that request in writing and present that request to the HIPAA Compliance Officer or the Administrator of the above facility who will deliver it to the Privacy Officer. I understand that this revocation will not apply to the information that has already been released or to information that is required by law by my insurance company.

This authorization will expire 6 months from today’s date or earlier if I specify a date here

Date

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization and my treatment will not be altered. I understand that I may see or copy the information to be used or disclosed.

By submitting the information below, you are electronically signing this form.

Patient's name*

Birth date*

Date

Your name and relationship, if you are the patient's personal representative

Authorization to Release Protected Health Information