Indiana Breast Center Patient Records Request Form

PLEASE READ THE FOLLOWING INSTRUCTIONS

If you are requesting free electronic access to your records, please fill out the first page of this form, submit the form, and disregard the payment page.

If you are requesting a HARD COPY of your records to be mailed to you, please complete the first page, submit the form, AND complete the payment page. The fee for HARD COPY records is $25.00.

RESULTS ARE CURRENTLY TAKING APPROXIMATELY 1-2 WEEKS TO PROCESS

Patient First Name *
Patient Last Name *
Previous Last Name (If Applicable)
Medical Record Number (Included in your Notification Letter if applicable)
Email Address *
Telephone Number * - ### - ### ####
Patient Date of Birth * / MM / DD YYYY
Drivers License

By providing your drivers license information, we are able to expedite your request for patient records.
Drivers License # *
Drivers License Issuer
Describe Medical Records Requested including Dates of Service *
Address to Send Records

Please provide the address where medical records should be sent.
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Fax my Reports (optional)

Please provide a fax number if you would like non-imaging records to be faxed.
Phone - ### - ### ####
Authorization

I hereby authorize Purview, records custodian of Indiana Breast Center, to release Radiology information including mammography images and reports as needed for comparison purposes.
Draw your signature into the box below.

Clear

Indiana Breast Center Patient Records Request Form

Indiana Breast Center Patient Records Request Form

PLEASE READ THE FOLLOWING INSTRUCTIONS

Drivers License

Address to Send Records

Fax my Reports (optional)

Authorization