Get Ma General Hospital Form B: Authorization For Release Of Ct Dental Images 2018-2025

This guide provides a step-by-step approach to filling out the MA General Hospital Form B: Authorization For Release Of CT Dental Images online. By following these instructions, users can ensure that their requests for dental images are processed efficiently.

Follow the steps to complete the authorization form accurately.

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 to print it clearly to avoid any misunderstandings.
3. Next, fill in the medical record number and date of birth for proper identification. This information is important for the hospital to locate the patient's records.
4. Indicate your authorization by checking the box stating ‘I hereby authorize Massachusetts General Hospital to furnish medical images from my image file.’
5. Provide the dentist’s name and phone number in the appropriate fields. Accurate contact information is essential for effective communication and delivery.
6. Select the mailing preference by checking the appropriate box: either to the patient or the new dentist. Fill in the mailing address if necessary, ensuring all details are correct.
7. Enter the date of study in the designated field. This helps in identifying the specific imaging required.
8. Choose the media type from the available options. Specify if you want a Simplant CD, Simplant Pro CD, Simplant View, or DICOM CD to meet your dentist's software requirements.
9. If shipping the images via FedEx, provide the FedEx account number or credit card number for billing purposes.
10. Sign the authorization form in the specified area and date it to validate your request before submission.
11. Once all fields are completed, save your changes. You can then download, print, or share the form as needed.

Complete your authorization form online today to ensure a smooth release of your dental images.