Get Mri-x-ray-image-release-form.doc. Schedule A - Source Modified: 2013-04-17 08:40:42 2020-2025

The MRI/X-ray image release form is an essential document required by Upper Bucks Orthopaedics to facilitate the release of medical images. This guide will help you understand and complete the form accurately and efficiently.

Follow the steps to fill out the MRI/X-ray image release form with ease.

1. Select the ‘Get Form’ button to access the form. This action will allow you to download and open it in your preferred editing tool.
2. In the section labeled 'Patient Name', enter your full name as it appears in your medical records.
3. Provide your date of birth in the designated field to confirm your identity.
4. Indicate the type of images you are requesting by checking the appropriate box for X-rays or MRI, each with their respective fees.
5. If the films being requested were obtained prior to October 31, 2011, note that you will receive the original films. Be sure to acknowledge that these films must be returned within 30 days.
6. Fill in the 'Body Part' section with the specific area of your body that corresponds to the images you are requesting.
7. Input the 'Date of Service' when the images were taken.
8. Enter the total 'Number of Films' you are requesting for release.
9. Record the 'Date of Request for Release' to document when you submitted the request.
10. In the 'Reason for Release of Images' section, provide a brief explanation of why you need the images.
11. Ensure that you or your legal representative signs and dates the form to validate the request.
12. Finally, upon completing the form, remember to save your changes, download the file, print it if necessary, or share it as required.

Complete your documents online today to ensure a smooth process for the release of your MRI or X-ray images.