№ lp_2_1_01263
Medical authorization form establishing consent, conditions, and procedures for the disclosure of radiology images and related protected health information to a designated recipient.
Organization: Boston Children’s Hospital
Department: Image Service Center
Address: 300 Longwood Avenue, Boston, MA 02115
Additional Location: 9 Hope Avenue, Waltham, MA 02453
Contact Phone: 617-355-6283; 781-216-1100
Fax: 617-730-0538
Document Type: Medical records release authorization form
Subject: Release of radiology images and related protected health information
Validity Period: 90 days from the signature date
Signature Requirement: Patient aged 18 or older, emancipated minor, or parent/legal guardian for minors
Identification Requirement: Picture I.D. required for image pickup
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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