Authorization to Obtain Medical Records

Patient First Name*
Patient Last Name*
Former/Maiden Name
Date of Birth*
MM slash DD slash YYYY
Phone*
Email
Where did you have your previous imaging?
Facility Name*
Facility Telephone Number*
Fax*
Facility Address
City
State
Zip
Record Type
- MAMMOGRAM/BREAST IMAGING AND REPORTS
- OTHER IMAGING
Type of Imaging
Dates of Service
Please send DICOM images and reports. Powershare preferred.
Entity Authorized to Receive and Use
Send To: Delaney Radiology 1025 Medical Center Drive
Wilmington, NC 28401 Phone: (910) 762-3882 Fax: (910) 332-0387
I authorize Delaney Radiology to obtain any information needed in the course of my treatment, as well as release any information needed or obtained in the course of my treatment to physicians and/or other medical providers where treatment is, or may be rendered, as well as the person(s) listed above.
I understand that this authorization will expire one year from the date I sign this form. I also understand that I may revoke this authorization at any time by sending written notice of my revocation to the Contact Office listed below. Revocation will be effective on the date of receipt except to the extent that action has already taken in reliance upon it.
Contact Office: Delaney Radiology Privacy Officer, 1025 Medical Center Drive • Wilmington, NC 28401 Fax: (910) 343-6019
Please check who is completing and signing this authorization.*
- Individual
- Personal Representative on behalf of the Individual
Personal Representative’s Name*
Relationship to Individual*
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION AND THE REQUEST WILL BE CONSIDERED NULL & VOID.
Authorization will be included in the individual’s medical record.
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

*Note: Once you submit the form, if you do not get redirected to a page that says your request was submitted successfully,
please refresh this page and try submitting the form again.

Authorization to Obtain Medical Records

Where did you have your previous imaging?

Please send DICOM images and reports. Powershare preferred.

Delaney Radiology