Medical Record Request

Patient's Information:

I, the undersigned, hereby authorize Doral Imaging Institute DBA CIRA, 2760 SW 97th Ave STE B101, Miami, Fl 33165, to provide my medical record.

Release Records To:

I understand that the entire medical record, including information pertaining to drug or alcohol abuse information should not be released.

Release or transfer of the specified information to any person or entity not specified herein is prohibited. An additional written consent must be obtained for a proposed new use of the information or for its transfer to another person or entity.

I understand that I have a right to receive a copy of this authorization upon my request.