Get Westmed Mammogram Form

Filling out the Westmed Mammogram Form online is a straightforward process designed to ensure that your request for release of radiology materials is clear and efficient. This guide will walk you through each step, ensuring you provide all necessary information accurately.

Follow the steps to complete the Westmed Mammogram Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name in the designated field. Ensure that the name matches identification documents to avoid any discrepancies.
3. Next, input the patient’s date of service. This information is crucial for locating the correct mammography images and reports.
4. Fill in the patient's date of birth to further confirm their identity. This will assist in ensuring the records are matched accurately.
5. Enter the date of your request in the appropriate field. This helps track when the request was made.
6. Specify the name of the institution where the previous mammography was performed. Accurate details for this section facilitate the retrieval of medical records.
7. Provide the radiology department’s telephone number. This field is useful for any follow-up communications regarding the request.
8. Enter contact information for the person filling out the form, ensuring that it includes a reliable phone number or email where they can be reached.
9. You must indicate that you request the release of mammography images and reports by completing the relevant fields to confirm the destination of the materials — in this case, WESTMED Medical Group.
10. Sign the form in the designated area, confirming your understanding of the terms provided, including authorization to release medical records.
11. Finally, review all entries for accuracy before saving changes. You can download, print, or share the completed form as needed.

Complete your Westmed Mammogram Form online today to ensure a smooth release of your medical records.