West Bloomfield Prior Release

I request and authorize my mammography medical records to be released from:*

Please select facility name

If Other, please specify below:*

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Long Answer

Prior Exams Requested

Dates

Long Answer

This authorization permits the Prior Health Care Provider to use and/or disclose the following individually identifiable health information about me to Women’s Health and Menopause Center, P.C.

Prior Exams Requested:

Mammography Exams on CD/DVD

Dates:

Most recent 4 years of exams

Records should be mailed and/or faxed to:

Women’s Health and Menopause Center, P.C.

5777 West Maple Road

Suite 200

West Bloomfield Township, MI 48322

Phone: 248-932-9223 ex:245

Fax: 877-220-1893

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

Patients Name:*

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 Women’s Health and Menopause Center, P.C.

. We thank you in advance for your attention to the prompt release and delivery of her prior studies to us.

Signature of Patient or Legal Guardian:*

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