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234 E 1ST STREET, STE 242, CASPER, WY 82601

407 S MEDICAL ARTS CT, STE E2, GILLETTE, WY 82716

PHONE (866) 678-4699 | FAX 833.992.2034

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Authorization for Release of Medical Records

Patient Name

Date of Birth

Address

Records Requested

Reports

Images

Billing

All

Exam(s) Needed

Date of Exam

Previous Name (if different)

Medical Records # (if known)

Phone

Notes:

I hereby authoize The McGinley Clinic / Elite Imaging Center to release the requested medical rcords to the following facility / physician:

I hereby authoize you to release the requested medical records to The McGinley Clinic / Elite Imaging Center.

Patient or Legally Authorized Representative Signature

Select a date

Printed Name:

Relationship to Patient:

*** We use AMBRA Health Imaging Management and can send imaging electronically to most locations.

*** There is a $25 fee to have your imaging printed and mailed.

Thank you!

The McGinley Clinic

234 E 1ST STREET STE 242, CASPER, WY 82601
407 S MEDICAL ARTS CT, STE E2, GILLETTE, WY 82716
PHONE (866) 678-4699 | FAX 833.992.2034

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