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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