NCRG | Copies of Examinations

Request from *

Clarence Valley Imaging

North Coast Radiology

These are required for *

a Health Care Provider

yourself

Please provide

You can request a specific examination or all examinations.

Date required

e.g. when is your next health care provider appointment?

Specific Examination/Study Information

Indicate the specific examination or most recent examination if requesting more than one

Date of Examination

Patient Information

Name *

(first name and surname)

Date Of Birth *

Best Phone Number *

(inc area code)

Email *

Electronic or hard copy

Electronic

Hard Copy

Electronic - an SMS will be sent roughly 2 working days after the request has been processed. The report(s) will be a further 6 days after this. Hard Copy will require you to come into a branch.

Mobile Phone

This is the number a link to the images will be sent to.

Which branch do you want to pick them up from?

Collection by

(Please enter name of person collecting if not the patient. We will call you to confirm at time of pickup)

Practitioner information

(We will need to contact this practitioner directly)

Practitioner name *

(eg Dr John Smith)

Practice name and address *

Please indicate what Format you are requesting copies for your Health Care Provider?

(Note that copies may incur a fee. Requests for physical film will require the patient to collect directly from patient's local branch)

Practice phone number *

Practice fax number *

Consent and Sign off

I hereby agree to the following conditions *

Yes

I acknowledge and agree that:
1. I understand that I will not be permitted to remove the contents of my medical record from the premises of the North Coast Radiology Group premises, nor will I be permitted to alter or erase information contained in the medical record.
2. I will be permitted to obtain copies of some or all of the contents of my medical record. Where copies are requested, a fee may be applicable. Further, I understand that copies may not be available at the time of inspection of my medical record, and will be made available to me as soon as practicable following the inspection.
I acknowledge and agree that:

Where this request is for hard copies not previously supplied at the time of my original appointment, an administrative fee of $22.00 may apply to my request. Further, provision of copies of printed pages will be at the cost of $2.50 per page, and provision of images will be at the cost of $22.00 per film and/or $22.00 per disc. These costs are inclusive of GST. If I have a condition that is suitable for inclusion in a clinical trial I consent to being contacted by the clinical trial coordinator about possible inclusion, and I understand that I can decline any such offer of inclusion at any time.

Where the request relates to requesting radiology examination images and or reports be made available to a new provider eg a specialist who is not local I am consenting to North Coast Radiology Group transfering the result/s of my examinations electronically to that new provider per the details provided within this form or subsequently over the phone.

Signature *

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Copies of Examinations