Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Release my medical records from:
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CRL Imaging Southdale/ Women's Imaging
CRL Imaging Plymouth
Other
Send my medical records to:
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Attn: CRL Imaging Southdale/Women's Imaging, 6525 France Ave South, Suite 110, Edina, MN 55435 Phone: 952-915-4320 Fax: 952-915-4338
Other
Information to be released
*
Images on CD
Report
Date(s) of Service
*
If you don't remember your date, please submit the year(s)
What was the service?
*
CT
Bone Density
Fluoroscopy
Mammogram
MRI
Pain Management
Ultrasound
X-Ray
Other
Date Information is Needed:
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-
Month
-
Day
Year
Date (Allow 48 hours to process request)
Release Method:
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Mail
Pick-up
Email
Self
Representative (provide full name in box below)
Purpose of Release:
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Continuing Care
Transfer of Care
Other
*Fees may be charged in accordance with MN statute 144.292 or Federal Rule 45C.F.R
Today's Date
*
-
Month
-
Day
Year
Date
Digital Signature
*
Terms & Conditions
This authorization lasts for one year after the date it is signed. This authorization may be cancelled in writing at ANYTIME. A cancellation will not change the releases’ that happen prior to the time the cancellation notice is received. TO CANCEL A RELEASE, call or send a request to the “Requested Release Form” address above. A photocopy or fax of this authorization will be treated the same as an original. Consulting Radiologists, Ltd. and its affiliates; CRL Imaging, CRL Women’s Imaging, LifeScan Minnesota, and Twin Cities Medical Imaging CANNOT prevent re-disclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by the State and Federal privacy protections once it is released. By signing the document below, you release Consulting Radiologists, Ltd. and its affiliates; CRL Imaging, CRL Women’s Imaging from any liability from a re-disclosure by the recipient. Consulting Radiologists, Ltd. and its affiliates; CRL Imaging, CRL Women’s Imaging WILL NOT condition treatment on whether you sign this form. By checking the 'I accept' box BELOW, this form indicates that you have read and understand this form, authorize release of your information as described above. *CRL is not responsible for loss of information submitted online through our secure form.
*
I accept the TERMS & CONDITIONS
Submit
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