The following is the form for release of patient information. If you do not want to submit this online, please download a hard copy to be submitted to your designated clinic in person or by mail to designated imaging center.
PDF form downloads: CRL IMAGING & CRL WOMEN’S IMAGING
*Please note that if you are filling out the online form, the provider releasing the information and the receiving party should be two different locations. If you need assistance with our imaging center locations check out the OUR LOCATIONS page CLICK HERE.