Request Patient Film


 

We request you to follow the below mentioned steps so that we can maintain privacy:

  1. Please fill out the below: “Authorization to Release Protected Health Information”. Fill out the details and sign and enter the date on the form.
  2. Direct to Provider. The easiest and safest means is to send your records to your medical provider is through a secure electronic line. Submit the “Authorization to Release Protected Health Information” form via fax with a photo copy of your valid identification to (602) 302-5958.
  3. Fax Request / Direct to Patient. You may submit a request to get the medical records via fax. Please fax the completed “Authorization to Release Protected Health Information” form and a photocopy of your valid identification to 623-815-8299. All requests will be processed within 1 week of request receipt.
  4. Collect in Person. You may pick up your medical records by hand carrying the form and a valid identification to any Sun Radiology Imaging center

Please note: A fee of $25.00 per set applies for any film request. As a courtesy to our patients, any request for reports and/or a CD containing images will be provided at without charge. If the “Authorization to Release Protected Health Information” form is incomplete, you will be contacted by a Medical Record staff member from Sun Radiology to request additional information.

Authorization to Release Protected Health Information
PLEASE FILL OUT EACH SECTION BELOW

To Disclose My Records:(Please check the exam(s) for which you are requesting reports/images)
Are you requesting (check all that apply):
Please note, a $25.00 fee per set of films and CDs are promptly prepared at the time of pick up.
Please indicate how you would like these to be received:
I understand that my records will only be provided to myself or any individual(s) I listed below. A photo ID is required at the time of pickup
By my signature below, I authorize SimonMed Imaging to release my protected health information to the following individual(s):
I understand that after the custodian of records discloses my health information, it may no longer be protected by federal and/or state privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, payment, eligibility for benefits unless allowed by law. I understand this authorization maybe revoked in writing at any time, except to the extent that action has been taken in reliance on the authorization. Unless otherwise revoked, this authorization will expire 1 year from date of signature. You have the right to revoke this authorization,except to the extent the custodian of records has relied on it, by sending your written request to the Privacy Officer at: 6900 E. Camelback Road, #700 Scottsdale, AZ 85251
Patient or Authorized Representative Signature
Date of Signature
Printed Name of Patient or Authorized Representative
Relationship to Patient
Phone: (623) 815-8200
Fax (623) 815-8299
FM.HIM001
UPDATED: 03/31/2023