Patient First Name*

Patient Last Name*

Patient Date of Birth (MM/DD/YYYY)*

Last Four Digits of Patients Social Security Number*

Attorney Name (First, Last)*

Attorney Phone*

Attorney Fax*

Request Submitted By*

Contact Number*
Click here to download the HIPAA Authorization Form
Please upload Completed HIPPA Authorization Form

By clicking the submit button, you are hereby certifying that you are the individual stated above and you authorize University Diagnostic Medical Imaging to process this request. Please refer to our privacy policy for our specific privacy practices.