MAMMOGRAPHY PRIOR RELEASE FORM

MEDICAL PRIOR RELEASE FORM

You are welcome to fax or drop off the completed Medical Prior Release Form at our office. However, if you prefer to submit this form electronically, there are three ways one can do so. Follow the instructions below. NOTE: BY SUBMITTING THIS FORM ELECTRONICALLY, WE CANNOT ASSURE YOU THAT IT IS SECURE.

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Instructions on HOW TO Sign & Send Medical Prior Release Form Electronically

 Option 1 

1. Save this MEDICAL RELEASE FORM to your desktop. 
2. Open up this online eSign tool. 
3. Drag and drop the Medical Release Form PDF into the eSign toolbox.  
4. Once it loads, click 'Text Field' to complete the form, and 'Checkbox' to fill in the information requested. 
5. Select 'Create your signature' and drag your signature onto the document. 
6. Select 'Text Field' to add a DATE to the document. 
7. Hit ‘Finish & Sign’ and download or save your signed PDF to your desktop. 
8. Submit via email to medicalrecords@obgyngroup.com.   

 Option 2 

1. Save this MEDICAL RELEASE FORM to your desktop. 
2. Right-click on the saved Medical Release Form > Open with Adobe Acrobat Reader DC 
3. Select 'Fill & Sign' Click on each line to enter all requested information. 
4. Place an X or Check Mark in the boxes, as requested. 
5. Select 'Sign' to create and/or drag and drop your signature onto the document. 
6. Enter today's Date Save the completed PDF to your desktop. 
7. Email to medicalrecords@obgyngroup.com.

 Option 3 

1. Download the MEDICAL RELEASE FORM to your smartphone device.
2. Complete all required information.
3. Sign & Email to medicalrecords@obgyngroup.com.

 Again, if you would rather not submit this form electronically, you are welcome to drop it off at our office at 5350 Eastern Ave., Davenport, IA, or FAX to 563.359.1512.

NOTE: BY SUBMITTING THIS FORM ELECTRONICALLY, WE CAN NOT ASSURE YOU THAT IT IS SECURE.