Patient Name :
Claim/ Reference No. :
Name of Insurance Company/ Employer/ Law Office requesting test:
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
I authorize St. Joseph's Heathcare Hamilton to release my medical imaging results to the entities named above. ____________________________________________________
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.