Get Radnet Form.pol.004 2015-2025

This guide provides detailed instructions on how to complete the RadNet FORM.POL.004 online. By filling out this medical record release request form, you will enable access to your prior medical records for comparison with new exams, facilitating better healthcare decisions.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editing platform.
2. In the 'Patient and Requestor Information' section, fill in the patient’s name, medical record number (MRN), contact phone number, date of birth (DOB), and the name of the person or physician requesting the records. Include details of any verbal orders taken, along with the date and time.
3. In the 'Type of Medical Record Requested' section, check all applicable boxes, including reports, images on film, and images on CD. Be sure to specify the exams and service dates in the provided space.
4. For the 'Purpose of Medical Record Request' section, check all relevant reasons for the request, such as doctor appointments, comparisons, or surgery. You can also specify 'Other' if needed.
5. Indicate the preferred 'Delivery Method' for the records. Choose from options such as picking up at the center, mailing, e-mailing, certified mail, or faxing. Be sure to provide the necessary addresses or contact details.
6. If applicable for mammography requests, indicate whether the original films and reports are to be released for permanent transfer or for 30 days.
7. Review the 'Patient Authorization' section. By signing, the patient agrees to the terms outlined regarding privacy and how their records will be used. Include the requester’s signature and date.
8. If submitted by mail, email, or fax, confirm whether the patient's signature has been compared to the signature on file, checking 'Yes' or 'No' as appropriate.
9. Complete the 'Medical Record Release Fees' section by noting any applicable fees associated with processing the request, referring to the details laid out in this section.
10. In the 'ID Verification' section, confirm that the identification of the patient or authorized representative has been verified. Document their printed name, date, signature, and relationship to the patient.
11. Finally, for internal use, ensure that the medical records are prepared and verified by the designated staff, completing any necessary employee signatures.
12. Once all sections are completed, save changes to the form, and choose to download, print, or share it as needed.

Complete your medical record release request online now for a streamlined experience.