Pay My Bill
Patient Portal
Referrer Portal Login
Medical Records
Request an Appointment

910-762-3882 | Fax: 910-762-6739

Home
About Us
Services
Women’s Imaging
For Patients
For Physicians
Contact Us
Menu Menu

Medical Records Release Form

"*" indicates required fields

*If you are a law firm, please fax your request along with a patient authorization form to (910) 332-0387.

First Name*

Last Name*

Former/Maiden Name

Date of Birth*

MM slash DD slash YYYY

Email*

Phone*

Records Are to Be*

Picked up by Patient (pick up at 1025 Medical Center Drive)

Picked up by Authorized Representative (pick up at 1025 Medical Center Drive)

Mailed

Faxed (report only)

Powershare (medical facility only)

Please select one:*

Images on CD (contains report)

Report only

Send/Release Records To:

Name of Person or Entity Authorized to Receive Information*

Street Address*

City*

State*

Zip*

Phone #*

Fax # (required for faxed reports)

Records Requested*

X-Ray

Mammogram

Ultrasound

CT Scan

MRI

Dexa

Other

Please list other records requested

X-Ray Date From

MM slash DD slash YYYY

X-Ray Date To

MM slash DD slash YYYY

Mammogram Date From

MM slash DD slash YYYY

Mammogram Date To

MM slash DD slash YYYY

Ultrasound of Body Part

Ultrasound Date

MM slash DD slash YYYY

CT Scan of Body Part

CT Scan Date

MM slash DD slash YYYY

MRI Body Part

MRI Date

MM slash DD slash YYYY

Dexa Date From

MM slash DD slash YYYY

Dexa Date To

MM slash DD slash YYYY

All Records Date From

MM slash DD slash YYYY

All Records Date To

MM slash DD slash YYYY

Reports Only Date From

MM slash DD slash YYYY

Reports Only Date To

MM slash DD slash YYYY

Please Note

If you have already submitted a request via website, phone or fax and have not heard from us within 48 business hours, please contact us at (910) 341-1840. Please do not make multiple requests as this will cause a delay in receiving your records.

Email

This field is for validation purposes and should be left unchanged.

*Note: Once you submit the form, if you do not get redirected to a page that says your request was submitted successfully,
please refresh this page and try submitting the form again.

Delaney Radiology

Medical Center Drive Office:
1025 Medical Center Drive
Wilmington, NC 28401

Tel: (910) 762-3882

Fax: (910) 762-6739

Email: info@delaneyrad.com

Office Hours: 7:30 AM-5:00 PM

Locations
Careers
Medical Records
Referrer Portal

Contact Us
Pay My Bill
Patient Portal
Blog

© Copyright 2024 - Delaney Radiology

Facebook
Instagram

Locations
Contact Us
Careers
Referrer Portal Login
Privacy/HIPAA
Patient Portal
Search
Pay My Bill