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AUTHORIZATION FOR RELEASE OF PRIVATE HEALTH INFORMATION (PHI) Permission for PinnacleHealth Imaging/ Tristan Radiology Specialists to release information Print Patient Name: Social Security #: Street

How to fill out permission for pinnaclehealth imaging

How to fill out permission for PinnacleHealth Imaging:

1. Obtain the permission form: First, you need to obtain the permission form for PinnacleHealth Imaging. This form is typically available on their website or can be obtained from their office.
2. Provide personal information: Fill out your personal information accurately in the designated fields on the form. This includes your full name, date of birth, address, contact number, and any other required information.
3. Specify the purpose: Indicate the reason for seeking permission for PinnacleHealth Imaging. This could be for diagnostic imaging such as X-rays, MRI scans, CT scans, or any other specific purpose. Provide as much detail as possible to ensure the correct services are authorized.
4. Choose the location: PinnacleHealth Imaging may have multiple locations where imaging services are offered. Select the desired location where you would like to undergo the imaging procedure.
5. Consent for treatment: Read and understand the consent section of the form carefully. This section usually states that you are giving permission for the medical professionals at PinnacleHealth Imaging to perform the required imaging procedures as deemed necessary.
6. Signature and date: Sign and date the permission form to validate and indicate your agreement to the terms and conditions. Make sure your signature matches the name provided on the form accurately.

Who needs permission for PinnacleHealth Imaging?

1. Patients: Any individuals who require medical imaging services at PinnacleHealth Imaging need to obtain permission. This includes patients with suspected injuries, illnesses, or those undergoing regular check-ups.
2. Minors: If the patient is a minor (under the age of 18), a parent or legal guardian needs to provide permission on their behalf. The parent or guardian will need to fill out the permission form and provide their own information along with that of the minor.
3. Legal representatives: In some cases, if a patient is unable to provide permission themselves due to a physical or mental condition, a legal representative such as a healthcare proxy or power of attorney may need to provide permission on their behalf. This should be done according to the legal guidelines in your jurisdiction.

It is important to note that the specific requirements for permission may vary based on the policies and procedures of PinnacleHealth Imaging. It is always best to consult with their office directly for any specific instructions or additional documentation that may be required.

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