Get West Valley Imaging

This guide provides clear and comprehensive instructions for filling out the West Valley Imaging authorization form for the use or disclosure of medical record information. Follow these steps to ensure accurate and complete submission of your information.

Follow the steps to successfully fill out the West Valley Imaging form.

1. Click the ‘Get Form’ button to obtain the authorization form and open it in the designated editor.
2. Begin by entering the patient’s full name in the appropriate field. This should be the individual whose medical records are being requested.
3. Provide the patient’s date of birth, ensuring the format is consistent with the form requirements.
4. Fill in the patient's address, including the street, city, state, and zip code for accurate identification.
5. Enter the patient’s email address and phone numbers—both home and work—if applicable.
6. Indicate the individual or facility to which the medical records should be released by filling out the 'Release Information To' section, including their name, address, and phone.
7. Specify the information to be released by checking the appropriate boxes for the records you wish to include (e.g., progress notes, labs, radiology reports, etc.)
8. Provide the date range for which you would like the records, ensuring that the start and end dates are complete.
9. If applicable, initial the boxes for the protected information that you authorize to be released, such as psychotherapy notes, mental health information, and substance abuse information.
10. Review the completion of the form. Ensure that all necessary fields are filled out correctly and that any initialing has been completed.
11. Sign the form where indicated, confirming your authorization. If applicable, the parent or legally recognized representative should sign as well.
12. Include any necessary documentation to confirm authority when acting on the patient’s behalf.
13. Once completed, save changes to the form and consider downloading, printing, or sharing it as needed. Submit via email or fax to the provided contact information.

Complete your authorization for medical record release online today!