Image Service Center
75 Francis Street
Boston, MA 02115
Telephone: (617) 732-7180
Fax: (617) 732-5300
Authorization for Release of Medical Images Information
Patient Name: Date of Request:
(print please)
Medical Record #: Date of Birth:
I hereby authorize Brigham and Women’s Hospital furnish medical images and Radiology Reports from my
image file to:
Name:
Street Address:
City, State, Zip Code:
Date of Exam(s):
Exam(s):
.
(Specific Information Required., Print please)
Digital images on CD should not be returned. IunderstandthattheCompactDiscs(CD)tobereleasedcontainsa
copyofmymedicalimages.IherebyreleasetheBrighamAndWomen’sHospital,Inc.anditsagentsand
employeesfromallliabilitythatmayarisefromthereleaseoftheCompactDisc(CD).
I understand this policy as it has been explained to me.
I acknowledge receiving CDs, ORIGINAL Films Radiology Reports.
(Check all that apply)
Thank you in advance for handling these images with care and, if you are borrowing original films, for returning
them to the Brigham and Women’s Image Service Center.
Date
Patient Signature or Signature of Presenter (if not Patient)
ISR Initials:
Relationship of Presenter
