Download SMDI Request for outside films - Sugar Mill Diagnostic Imaging

more than just x-rays
I, _____________________________________________, give permission to Sugar Mill Diagnostic Imaging to
obtain previous films or records for comparison purposes from
Films or CD: _____________________________________________________________
Reports: ________________________________________________________________
Facility Name: ____________________________________________________________________________
Address: _________________________________________________________________________________
________________________________________________________________________________________
Phone: __________________________________________________
Fax: ____________________________________________________
Mail films/ CD
Pickup films/CD
Patient Signature: _________________________________________________________________
Date of Birth: _______________________________________
Today’s Date: _______________________________________
Note: This message may contain Electronic Protected Health Information. Re-disclosure without proper consent or
As permitted by law is prohibited. This message is intended for the use of the person/entity to which it is addressed
and may contain information that is privileged/confidential. If you are not the intended recipient, you are hereby
notified that any disclosure, copying or distribution of this information is strictly prohibited and is subject to
state/federal law penalties. If you have received this message by error, please notify the sender immediately.
www.smdi.net
8303 S. Suncoast Blvd • Homosassa, FL 34446
Phone (352)628-9900 • Fax (352)628-9700