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 Radiology Imaging Request FormNortheast Georgia Diagnostic Clinic1240 Jesse Jewell ParkwaySuite 500 Gainesville, GA 30501 office: 770-536-9864 Please Note:
This form should be used to request a Radiology CD from the Northeast Georgia Diagnostic Clinic. This request is for Radiology Images only.
If CD requested is for personal use, there will be a $10 charge per CD.
Requirements for Pick up: Images can be picked up at the Medical Record Dept. located at the Northeast Georgia Diagnostic Clinic West Entrance. Due to HIPAA regulations, please have Photo I.D. available to present to the Medical Records attendant. You will also be required to sign a release of authorization prior to receiving your images. Patient Designee for Image Pick up if Patient Unavailable: If the patient is unavailable to pick up images, after submitting the request form, please print and send with whomever he/she designates for film pick up. The designee must bring the signed request form. Due to HIPAA regulations, they must present his/her Photo I.D. to the Medical Records attendant and will be required to sign a release of authorization prior to receiving your images. |
Patient Release Form
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