Records Release Form
//

Information to be released from:

Ultimage Orthopedics
1951 SW 172nd Ave #200,
Miramar, FL 33029
Tel: (954) 730-5030
This authorization is effective immediately and is subject to revocation at any time, except that action has already been taken. Otherwise, the authorization expires 1 year from the date of signing. I understand that this is a required consent and that I must voluntarily and knowingly sign this authorization BEFORE any records can be released and that I may refuse to sign. I further release my attending physician, consultants, the facility, and employees from any liability arising from the release of information to the person(s) / agency designed above. I understand that I have the right to receive a copy of this authorization upon my request.

I agree to pay the following

● For Records - $0.25 per page ● For In-Office Images - $25.00 ● Minimum of $5.00 when using credit cards (not applicable to debit cards)

Priority

-------OR---------