Patient authorization

Medical Records Release

To get your imaging order from your doctor, we need your written permission first. This form takes about two minutes — then we handle the phone calls, faxes, and follow-up for you.

About 2 minutes
Signed copy emailed to you
Revocable anytime

Complete your release

Two short steps: your details first, then your provider’s details and your electronic signature. Everything marked required is needed for your authorization to be valid.

Step 1 of 2

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Clinic Name

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Clinic Id

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Clinic Website

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Submitted URL

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Fax Number

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Clinic Phone Number

Name(Required)

First Name Last Name

Your Email Address(Required)

Your Phone(Required)

Sex assigned at Birth(Required)

Male

Female

Date of Birth(Required)

Address(Required)

Street Address City State ZIP Code

Order Information

Imaging Study Type(Required)

Body Part Requested(Required)

Provider Full Name(Required)

This is your doctor; it should not be yourself.

Provider Phone Number

This should be your doctor's office; it should not be yourself.

Signature for Medical Records Release(Required)

Your information is sent over an encrypted connection and used only to coordinate your imaging study. We never sell your information. Questions or revocations: info@expectedhealthcare.com.

Why we ask for this

It’s required by federal law

Your medical records are protected by HIPAA. Your doctor’s office can’t share your imaging order or results with anyone — including us — until you give written permission.

It lets us do the legwork

With your signed authorization, we contact your doctor’s office directly, obtain your imaging order, and coordinate with the clinic performing your study. No phone tag, no chasing paperwork.

Only what’s needed

Your authorization covers just the records tied to the study you list — nothing else. It expires on its own after a year, and you can revoke it anytime with a single email.

What happens after you sign

We request your order

We send your signed authorization to your doctor’s office and request your imaging order on your behalf.
We coordinate your study

Your order goes to the imaging clinic, and we make sure everything is in place for your appointment.
Results reach your doctor

After your study, reports go back to the provider you listed — and a copy of your signed authorization lands in your inbox from day one.

Not sure about something? We’re happy to walk you through it. Email info@expectedhealthcare.com or call (760) 539-1309.