Please select facility name
Please type facility name

This authorization permits the Prior Health Care Provider to use and/or disclose the following individually identifiable health information about me to GirlTalk & Gynecology.

Please send MOST RECENT 8 YEARS OF MAMMOGRAM IMAGES and U/S IMAGES W/ REPORTS (VPN or cloud image transmission preferred, CD/ DVD or film also can be accepted)

If you do not have films/CDs or any exams on this patient, please call our office.

Please mail the prior studies to :

The information will be used or disclosed for continuing medical care. 

Patient's Date of Birth:*
Today's Date:*

When my information is used or disclosed pursuant to this authorization, it may be Protected Health Information and subject to federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Prior Health care provider.

The timeliness of interpretation of this patient's upcoming mammogram is dependent on the provision of her previous studies to GirlTalk & Gynecology. We thank you in advance for your attention to the prompt release and delivery of her prior studies to us.

Use your mouse or finger to draw your signature above