Release of Medical Records

I, the undersigned, authorize the release of medical records including, but not limited to:

  • Radiology Reports and Images
  • Office Notes
  • Consultation Report
  • Operative Report
  • Lab/Pathology Reports

For the purpose of Continuation of Care. These records are to be released to:

Priority Radiology
807 Northgate BLVD New Albany, IN 47150
Phone: 812-949-0807
Fax: 812-949-0806

I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient. I understand that the specified information to be released may include but is not limited to history, diagnoses, and/or prior medical treatment.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been in reliance upon the authorization.

This authorization will not expire as long as I am still a patient of Priority Radiology.

I am a Legally Authorized Representative for the Patient