Request Imaging Electronic Transfer

Request for Electronic Transfer of Imaging

Only completely filled out requests will be processed. Most requests will be fulfilled within 3-4 business days.

Date *

Person Completing Form and Relationship to Patient (if applicable)

Name *

First

Last

Date of Birth *

MRN *

Requesting Physician *

Requesting Imaging *

Requesting Facility *

Facility Address *

Address Line 1

Address Line 2

City

State

Zip Code

Facility Phone Number *

What transfer method does requester use? *

Web address for Ambra?LifeImage?etc. *

Access Code *

Additional details/comments on this request (e.g. type of scans requested, specific dates, etc.)