Image Request

For Patients: All CD and film requests require 72-hour notice. The first copy for every exam is free. Please check with your doctor for the format they prefer (CD or film). The following fee schedule applies to duplicate copies: $25 per CD and $125 per set of films. The mailing fee is $2 for CDs. Films and reports cannot be mailed. In accordance with Florida Statute 766.1065, no one can pick up records on your behalf unless a signed Authorization to Release PHI form is in your chart. Please stop by the office to sign a form in person.

For Physicians: If you are not the original referring physician, a signed medical records release must be on file before the images and/or report can be released to your office.

* Required





EXAM REQUESTED







CD
Film

Pick-Up
Mail to Office

ONLY REQUIRED FOR MAIL DELIVERY