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Release of Personal Health Information Form

Requests for Copies of Medical Imaging Examinations

Patients who need copies of medical images will be asked to complete and sign a release form before the images are provided. This is to ensure that patients are provided the right images and privacy is protected.

If someone else will be picking your images for you, please complete the release form. Be sure to include the name of the person who will be doing the pick up. If you prefer to write a letter rather than complete the form, please include the following information: 

  • Your full name, date of birth and health card number
  • The type of images requested and dates taken (or hospital visit date)
  • The name of the person who will be picking up the CD of your images
Please Note:  The person picking up the images must provide Medical Imaging with your release form or letter. They will also be asked to provide photo identification and to sign your release form or letter to confirm receipt of your images. Allow 24 hours for us to process your request for film and CD pickup. 

Your privacy is important to us and we appreciate your cooperation in helping us make sure that your personal health information is protected.
 
Release of Patient Health Information Consent Form