To obtain a copy of your medical records for your personal files or have them sent to another facility, please complete and submit the form below.
You may also download and complete the form:
• This authorization may be canceled in writing anytime. A cancellation will not change releases that happen before the cancellation, was received: To cancel this release, call or send request to the address below:
Suburban Imaging Medical Records
6441 Cecilia Circle
Bloomington, MN 55439
• A photocopy/fax of this authorization will be treated the same way as an original.
• Suburban Imaging cannot prevent redisclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release Suburban Imaging from any and all liability from a re-disclosure by the recipient.
• Suburban Imaging will not condition treatment on whether you sign this form.
• Your signature indicates that you have read and understand this form, and authorize release of your information as described below.