REQUEST FOR RELEASE OF IMAGES AND REPORTS
Fax: (703)280-1527 Email: medicalrecords@washingtonradiology.com
Patient information
Patient Name: *
Previous/ Maiden Name:
Date of Birth: *
Telephone Number:
Receiving Party
I authorize Washington Radiology to release the following information to:
Name of Person or Entity
Street Address:
City:
State:
Zip code:
Information to be released
Dates of treatment:
Mammograms
MRI
CT
Ultrasounds
X-Rays
Bone Density Scan
Other:
be sure to select one or both options
Radiology Images on a disk
Imaging Reports
Method of delivery
Mail records to the address above
Email reports to:
(email only applies to reports, we cannot email radiology images.)
Fax reports to:
(fax only applies to reports, we cannot fax radiology images.)
I will pick records up from:
Select Washington Radiology Location
Please be mindful of our standard processing times.
  • Allow 3 – 5 business days when requesting to pick up records from one of our Washington Radiology locations, once your request has been processed a member of our medical records team will notify you that your records are ready to be picked up.
  • Allow 3 – 5 business days when requesting to have records emailed. Be aware that when you select this option you will receive the records in a secured email. You will be prompted to create a password to access the file. If in the future you forget this password, you will have the option to reset it.
  • Allow 3 – 5 business days when requesting to have records faxed.
  • Allow 7 – 10 business days when requesting to have records mailed.
Signature
Clear Signature
Protected Health Information (“PHI”) is information about you, including demographic information, that may identify you and that relates to your past, present, or future health and related health care services. Consistent with our Notice of Privacy Practices, Solis Mammography/Washington Radiology is required to obtain your authorization to permit the following use or disclosure of your PHI for purposes other than treatment, payment and health care operations. Solis Mammography/Washington Radiology will not condition its provision of services to you on whether you provide authorization for the requested use or disclosure. I understand that I may inspect or obtain a copy of the PHI of which I am being asked to allow the use or disclosure. I understand that I have the right to revoke this authorization at any time by sending such written notification to our Privacy Official via mail to Solis Mammography, Attn: Privacy Officer, 15601 Dallas Parkway, Suite 300, Addison, Texas 75001. Such a revocation will not be effective to the extent that Solis Mammography/Washington Radiology has relied on it for the previous use or disclosure of the PHI. If I sign this Authorization, I have a right to receive a signed copy of it. I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. This Authorization shall be in force and effective for 1 years from the date of my signature or until I revoke or terminate my authorization in writing, whichever is later, at which time Solis Mammography/Washington Radiology authorization to use or disclose the PHI specified expires.