Records Release FormPatient Name *FirstLastDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Information to be released from: Ultimage Orthopedics 1951 SW 172nd Ave #200, Miramar, FL 33029 Tel: (954) 730-5030Information to Be Released: Physician Note(s) Operative Report(s)In-Office X-ray/MRI/ Ultrasound Image Report(s)OtherThis 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)Guardian Name: *FirstLastRelationship to PatientPriorityUrgent RequestPickup at 1951 SW 172nd Ave #200 Miramar, FL 33029-------OR---------Non Urgent Request Mailing AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSubmitMedical Records Release Form