Imaging/Radiology Medical Authorization Release Form

Patient Information

Full Name Date of Birth Phone Number Address Insurance Provider Policy Number

Provider and Facility Information

Referring Physician Imaging/Radiology Facility Facility Address

Authorization and Release

I authorize the release of my medical imaging/radiology records as necessary for insurance claims processing.

Other (Please specify) Purpose of Release

This authorization is valid for the specific dates or services indicated and may be revoked at any time with written notice.