To assist you in obtaining the release of your medical records, please print out and use our medical release form.
When you are contacted by the Breastlink Patient Services Team, we can walk through the form together and answer any questions you may have.
Date: document.write(todaysDate()) 1/31/2009
This is to authorize:
Facility Name
Facility Address
Facility Phone
To release:
Medical records
Pathology slides and reports:
Date(s) of service
Procedure(s)
Breast Imaging films and reports
To: Breastlink Medical Group Inc.
Director of Patient Services
Patient’s name(printed):
Patient’s DOB:
Patient’s signature
Breastlink Medical Group Inc.
ATTN: Director of Patient Services
14650 Aviation Blvd. Suite 200
Hawthorne, CA 90250
Phone (310)539-2300 fax (310) 539-9185