Medical Records Request

We store all of your information in our medical records department, which is located at 3535 Quakerbridge Road, Suite 300, Hamilton, NJ 08619. Our film pick-up hours are Monday through Friday from 8:00am to 5:00pm. Should you ever need to pick up your medical records, please call 609-890-0033 x6231 or email us via the form below.

Patient First Name:

Patient Last Name:

Address:

City:

State:

Zip:

Date of Birth:

Parent / If Minor: *

Daytime Phone Number:

Cell Phone Number: *

Evening Phone Number:

Email Address:

Film/CD/Reports: Film
CD
Reports

Type of Study:

Date Study Performed:

Date Needed for Pick-Up:

Any additional information you need to provide? Please do so here: *

Terms & Conditions

I hereby authorize Quakerbridge Radiology Associates, P.A. from any legal liability that may arise from the release of the studies requested

As of 2008 all imaging studies are stored in our computer system. Quakerbridge Radiology will print films or create a CD containing a patient’s requested images at no cost for the first set. I understand that in the event the studies are lost or misplaced, I am subject to a replacement fee as follows. There is a $35.00 fee for MRI/CT films, a $15.00 fee for a replacement CD, and a per sheet fee of $7.00 to preprint plain films. I also understand that the requested images are not to be returned and are mine to keep with my personal records.

I understand that any disclosure of the information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I may inspect and/or copy the information about to be disclosed. I understand that authorizing this disclosure is voluntary. I understand that if I have any questions about disclosure of my health information, I may contact the privacy officer at the facility listed above that is authorized to disclose this information and request a copy of this authorization.

I have read and agree to all the terms above.

* denotes optional form field