HIPAA Authorization Form

NOTE: We cannot process any requests filed by attorneys without this form. The form must be completed fully and sent to the contact address or fax number below. If the attorney is going to request records with this form submission, he needs to send a check for $18.16 in processing fees along with this request.

Download a printer-friendly version of the HIPAA AUTHORIZATION FORM. ( Adobe Acrobat Reader required.)

Forms with attached processing fees can be mailed to:
Advanced Radiology
P O Box 475
Reisterstown, Maryland 21136

Forms that do not require a processing fee can be faxed to: 443-436-1298

If you have problems accessing the FORM please send an email to info@radiologix.com.