Medical Records Release Form

If you are a patient wanting a report of a past exam, please utilize the Patient Portal. If you are requesting images for your personal use, please select PowerShare in the options below. If you want a physical copy of your records, please visit our main office at 1025 Medical Center Drive between 8:00 a.m. and 5:00 p.m., Monday through Friday.

Results will be sent to your provider. Providers requiring images can request them via PowerShare. If additional items are needed, they may contact our office so we can assist them directly.

If you are a law firm requiring images, please fax your request along with a patient authorization form to (910) 332-0387.

If you do not see your request below, please contact our office at 910-762-3882, Opt.3.

"*" indicates required fields

First Name*

Last Name*

Former/Maiden Name

Date of Birth*

Email*

Phone*

Records Are to Be*

PowerShared (Click PowerShare and select Register Now)

Faxed (results only)

PowerShare

Fax # (required for faxed reports)

Records Requested*

X-Ray

Mammogram

Ultrasound

CT Scan

MRI

Dexa

Other

Please list other records requested

X-Ray Date From

X-Ray Date To

Mammogram Date From

Mammogram Date To

Ultrasound of Body Part

Ultrasound Date

CT Scan of Body Part

CT Scan Date

MRI Body Part

MRI Date

Dexa Date From

Dexa Date To

All Records Date From

All Records Date To

Reports Only Date From

Reports Only Date To

Please Note

If you have already submitted a request via website, phone or fax and have not heard from us within 48 business hours, please contact us at (910) 341-1840. Please do not make multiple requests as this will cause a delay in receiving your records.

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.

Medical Records Release Form

Please Note

Delaney Radiology