Get the free Salem Radiology Release Form

Date released: To be released from: Salem Radiology 31 Stiles Road Salem NH 03079 For the purpose of: Including the following portions of the record (s): Imaging×Radiology I, the undersigned, have

How to fill out salem radiology release form

How to fill out Salem Radiology release form:

1. Begin by obtaining the Salem Radiology release form from the healthcare facility or downloading it from their website.
2. Read through the form carefully to understand the information being requested and the purpose of the release.
3. Fill in your personal details accurately, including your full name, date of birth, address, and contact information.
4. Provide the specific dates or time period for which you are authorizing the release of your radiology records.
5. If applicable, indicate any specific procedures or tests you want to authorize the release for.
6. Sign and date the form, making sure your signature matches the one on file with the healthcare facility.
7. If required, provide the name and contact information of the authorized recipient(s) who will receive your radiology records.
8. Review the completed form to ensure all information is filled out correctly and that you have not missed any required fields.
9. Make a photocopy or take a picture of the completed form for your records.
10. Return the signed and completed form to the Salem Radiology office as per their instructions.

Who needs Salem Radiology release form:

1. Individuals who have undergone radiology procedures at Salem Radiology and need their records to be released to another healthcare provider.
2. Patients who have specific tests or imaging results that need to be shared with their primary care physician or a specialist.
3. Individuals participating in legal or insurance processes that require the release of their radiology records as evidence or for assessment.

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