Jefferson Regional Imaging Services

Jefferson Regional Imaging Services

1600 W. 40th Ave I Pine Bluff, AR 71603 - 870-541-7470
AUTHORIZATION FOR RELEASE OF MEDICAL IMAGES

X-Rays, Computerized Tomography (CT), MRI, Ultrasound, Nuclear Medicine, Mammography and PET CT
PATIENT IDENTIFICATION - I AUTHORIZE THE USE/DISCLOSURE OF HEALTH INFORMATION AS DESCRIBED BELOW FOR:
PATIENT NAME*
Date of Birth*

MonthDayYear
SSN*
WHO IS AUTHORIZED TO USE/DISCLOSE THIS INFORMATION?*

JEFFERSON REGIONAL MEDICAL CENTER AND OUTPATIENT CLINICS
WHO IS AUTHORIZED TO RECEIVE THIS INFORMATION?

If Self, write "SELF" on name and supply full mailing address
NAME/COMPANY*
EMAIL ADDRESS*
example@example.com
METHOD OF DELIVERY:

IMAGES will be sent by EMAIL or ELECTRONICALY to the Email address listed above.
Patient address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This request is for the release of Medical Imaging Exams:*

Computerized Tomography (CT)X-ray/Radiology ExamsMRIUltrasoundNuclear MedicineBreast Images (Mammography, Ultrasound and/or MRI)PET CT
Please list dates of service admission date and/or date ranges*

MonthDayYear
Start Date
End Date

MonthDayYear
If Applicable
INFORMATION IS NEEDED FOR:*

Continuity of CarePersonalInsurance, Billing, Legal or Disability
IF THE PERSON OR ENTITY WHICH RECEIVES THE INFORMATION IS NOT A HEALTHCARE PROVIDER OR HEALTH PLAN COVERED BY FEDERAL PRIVACY REGULATION, THE INFORMATION DESCRIBED ABOVE MAY BE REDISCLOSED AND NO LONGER PROTECTED BY THESE REGULATIONS.

I MAY REVOKE THIS AUTHORIZATION IN WRITING AT ANY TIME BY DELIVERING A COPY OF MY REVOCATION TO THE DEPARTMENT OF HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) AT JRMC. THIS AUTHORIZATION EXPIRES ONE YEAR FROM DATE SIGNED.

INFORMATION IN MY HEALTH RECORD MAY INCLUDE SPECIFIC INFORMATION RELATING TO SEXUALLY TRANSMITTED DISEASE, ACQUIRED IMMUNODEFICENCY SYNDROME (AIDS) OR HUMAN IMMUNODEFICIENCY VIRUS (HIV IT MAY ALSO INCLUDE INFORMATION ABOUT BEHAVIORAL OR MENTAL HEALTH SERVICES, AND TREATMENT FOR ALCOHOL AND DRUG USE OR ABUSE.
Attach Photo ID*
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL IMAGES

PATIENT IDENTIFICATION - I AUTHORIZE THE USE/DISCLOSURE OF HEALTH INFORMATION AS DESCRIBED BELOW FOR: