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Medical Records

Medical Records

Prior Imaging Records

To best serve our patients, Charlotte Radiology Breast Centers obtain prior breast images for review and comparison by our radiologists. These images should be received before each patient’s appointment.

Patients can expedite this process by completing the form below. Please click + to expand the form.

Authorization to Use or Disclose Protected Health Information Form Expand

"*" indicates required fields

MM slash DD slash YYYY
Patient's Address*

1. Authorized Persons To Use And Disclose Protected Health Information:

Location of Prior Images (facility name)

is authorized to disclose the following protected health information to:

Name: Charlotte Radiology
Street Address: 8514 McAlpine Park Drive, Ste 100
City, State, Zip: Charlotte, NC 28211
Phone: (704) 362-7060 Fax: (704) 362-7036

2. Description Of Information To Be Disclosed.

The health information that may be disclosed is:
The health information that may be disclosed is (choose one): Any and all imaging, billing, and administrative records Specify dates: (EXCLUDING discs of imaging studies)
The health information that may be disclosed is (choose one): Imaging study reports ONLY
The health information that may be disclosed is (choose one): Administrative records ONLY
The health information that may be disclosed is (choose one): Billing records ONLY
The health information that may be disclosed is (choose one): CD(s) of imaging studies

3. Purpose Of The Use Or Disclosure:

The purpose of this use or disclose is (choose one):*

4. Validity Of Authorization

This authorization is valid beginning as of the undersigned date and expires .

5. Acknowledgment

I understand: 1) I have the right to refuse to sign this authorization, and (covered entity) may not change or deny treatment on the condition that I sign this form. However, if left unsigned, (covered entity) may not be able to use or disclose the PHI as requested. 2) If signed, I have the right to revoke this authorization, in writing, at any time. If revoked, any action already taken in reliance on this authorization cannot be reversed, and the revocation will not affect those actions. 3) THE INFORMATION USED OR DISCLOSED UNDER THIS AUTHORIZATION MAY BE SUBJECT TO FURTHER DISCLOSURE BY THE PERSON(S) OR FACILITY RECEIVING IT AND COULD THEN NO LONGER BE PROTECTED BY FEDERAL PRIVACY REGULATIONS. (covered entity) IS NOT RESPONSIBLE FOR FURTHER DISCLOSURES BY A RECEIVING PARTY.

Covered Entity Address*
Location of Prior Images (facility address)
To consent to electronic signature, please check box*
MM slash DD slash YYYY
If Personal Representative Requesting:
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

Upload Prior Images Directly

Patients and providers can also easily and securely upload prior breast images directly to Charlotte Radiology from a storage device such as a CD, USB flash drive, or DVD using the Nuance PowerShare Easy Uploader Tool. The tool is convenient, fast, and HIPAA compliant, and gives our radiologists immediate access to the patient’s images.

For best results, we recommend using the browsers Google Chrome, Microsoft Edge, or Firefox to upload images for your storage device. Click the button below to access the PowerShare Easy Uploader.

PowerShare Easy Uploader

If you have any questions about using the PowerShare Easy Uploader, please contact PowerShare support at 1-866-809-4746.

Medical Records Requests

Charlotte Radiology Breast Centers have partnered with HealthMark Group to fulfill medical records requests for all breast imaging. To submit a request electronically:

  1. Visit https://requestmanager.healthmark-group.com.
  2. After logging in, choose "Submit Request" from the menu options.
  3. Complete all required fields to provide authorization directly to HealthMark.
  4. A notification will be sent via mail or email once your request is processed and available for
    download.

Requests may also be submitted via fax to HealthMark at 743-208-9321. Please submit a HIPAA-compliant authorization with your faxed request.

To follow up on the status of your medical record request, you may contact HealthMark Group directly at 800-659-4035 or charlotteradiology@healthmark-group.com.

To request records for DEXA Bone Density Exams, Diagnostic imaging services (such as a MRI, CT, or Ultrasound), or Screening mammograms completed at our Denver location:

  1. Please email a signed authorization to medicalrecordsclt@charlotteradiology.com or fax it to (704) 362-7036.
  2. For questions, please call 704-362-7060.

Patient requests: Request to Inspect or Obtain Copy of Patient Records

Third party requests: Authorization to Use or Disclose Protected Health Information

To request medical records from the Vein Center of Rosedale or SouthPark, please call 704-637-7877.

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