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Authorization to Obtain Protected Health Information

Records Obtained From
Records to be Sent to
MUSC Breast Imaging Center
1600 Midtown Ave.
Mount Pleasant, SC 29464

Fax Number: 843-876-8250
Phone Number: 843-876-8127

Purpose of Release: Continuing Care

Information to be Released:
- Radiology Images/DVD (NOT Included in Entire Record
- Mammograms

I understand this information may include reference to psychiatric/psychological care, sexual assault, drug abuse, results of tests for all infectious diseases including HIV/AIDS and/or alcohol abuse.

I understand that I have the right to cancel/revoke this authorization at any time. I understand that if I cancel/revoke this authorization I must do so in writing and present my written cancellation/revocation to the Health Information Service Department (Medical Records). I understand that the cancellation/revocation will not apply to information that has already been released in response to this authorization, as stated in the Notice of Privacy Practice. Unless otherwise canceled/revoked, this authorization will expire/end one year from the date below. I understand that only records available as of this date will be provided in response to this request. Should I need additional records in the future, a new request will be required.

I understand that authorizing the disclosure of protected health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to receive treatment. I understand I may review and/or copy the information to be disclosed, as provided in 45 CFR Section 164.524. I understand that any disclosure of information carries with it the possibility of authorized of unauthorized disclosure by the person/organization receiving the information. I understand I will be given a copy of this authorization.
Please enter your name as your signature.