Authorization for Release of Medical Records
Patient Information
Patient Name
Previous Name (if different)
Date of Birth
Address
City
State
Zip
Phone No.
Medical Records No. (if known)
Information Requested
Records Requested
Reports
Images
Billing
(Physical copies are subject to a $10 fee)
Exam(s) Needed
Exam Date
Or all exams needed
Yes
No
Exam(s) Needed
Exam Date
Exam(s) Needed
Exam Date
Notes
Authorizations
I hereby authorize Element Medical Imaging to release the requested medical records to the following facility/physician:
Name
Address
City
State
Zip
I hereby authorize you to release the requested medical records to Element Medical Imaging:
Element Medical Imaging
11717 West 112th Street
Overland Park, KS 66210
(Phone) 913-469-8998
(Fax) 913-469-5695
Patient or legally authorized representative Signature
(required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Relationship to Patient