Get Authorization For Release Of Diagnostic Images - Lahey

The Authorization For Release Of Diagnostic Images - Lahey is an essential form used to authorize the release of your diagnostic images. This guide will walk you through the process of completing the form online, ensuring clarity and ease at each step.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the Patient Information section. Include your LC Number if available, along with your full name, date of birth, and address. Ensure accuracy in the details provided.
3. Next, provide your contact information including home phone, work phone, and email address, ensuring to specify your city, state, and zip code.
4. In the 'Information to be Released' section, specify the dates of the exams and types of images you want to release. Be as detailed as possible to avoid misunderstandings.
5. Fill in the 'Mail Images to' section. State the name or facility to whom the images should be sent, along with the attention line, address, city, state, and zip code.
6. If applicable, indicate whether the patient will pick up the images in person or if someone else will be authorized to collect them. If someone else is picking up the images, remember to note that they must provide a signed authorization.
7. In the Release Information section, affirm that you are authorizing the release of the images by signing your name or that of your legal guardian.
8. Once you have filled out all sections, review the form for completeness and accuracy before submitting it. Save your changes, then proceed to download, print, or share the completed form as necessary.

Complete your Authorization For Release Of Diagnostic Images online today!