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Patient Release of Information / (Uninsured Services)



Patient Name :

Claim/ Reference No. :

Name of Insurance Company/ Employer/ Law Office requesting test:

( EG : WSIB )


Testing Arranged By:
MRI Appointments
York, ON N0A 1R0


Tel: 905 765 2620 Toll Free: 1 866 899 4674  /  Fax: 905 765 7099 Toll Free: 1 866 307 1247


Copies of the report to be sent to by fax:

1)__MRI Appointments - fax- 1 866 307 1247

2)



I authorize St. Joseph's Heathcare Hamilton to release my medical imaging results to the entities named above.
____________________________________________________

Patient Authorization:

Name:

Date:





In Ontario: This test qualifies for third-party funding because the information provided is required for insurance purposes or medical-legal reasons and qualifies as an uninsured service as defined by the Ontario Health Insurance Act (Ontario Regulation 552 Par 8 and Par 24) or the Workplace Safety Insurance Act.