Xray Release Form

This authorizes Reveal Diagnostics to release X-Ray and diagnostic records to the Requestor for purposes of providing the Requestor with Reveal Diagnostics diagnostic imaging records.
This authorization shall expire 30 days from the date this form is submitted.
By signing this request you agree to the following:
I understand that I have the right to revoke this authorization, and I must do so in writing. I understand that any such revocation will not affect any actions taken by Reveal Diagnostics in reliance on this authorization before its revocation. I understand that the Requestor may be able to redisclose protected health information provided by Reveal Diagnostics, and that the protected health information will no longer be covered by the federal privacy regulations implementing the Health Insurance Portability and Accountability Act of 1996.

Imaging Center Location
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Requestor Information

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State law requires this order be presented at the time of service. Payment in full is collected at the appointment.
Check, cash, Visa, Mastercard, Discover, Amex, Care Credit, HSA and FSA.
Phone 415-837-5990 ▪ Fax 888-808-6160 ▪ www.revealdiagnostics.com ▪ info@revealdiagnostics.com

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