REQUESTING RELEASE OF THE FOLLOWING IMAGES AND REPORTS
IMAGES AND REPORTS
LAKE MEDICAL IMAGING 801 East Dixie Ave, Suite 104 Leesburg, FL 34748 Phone: (352) 787-5858 Fax (352) 728-6074
The information will be used or disclosed for the following purpose: comparison and/or diagnostic evaluation.
This authorization remains effective for one year from the date signed.
Josh Floyd, Privacy/Compliance Officer