Authorization and Agreements

"*" indicates required fields

09/16/2025
Name*
MM slash DD slash YYYY
The undersigned hereby makes the following acknowledgement and agreement regarding the MRI/MRA/CT/Ultrasound/X-Ray/Mammography and Professional services to be provided to the patient whose name appears above.
CONSENT FOR MRI/MRA/CT/ULTRASOUND/X-RAY/MAMMOGRAPHY TECHNICAL/PROFESSIONAL SERVICES*
ENHANCEMENT CONSENT*
DIRECT PAYMENT AUTHORIZATION*
AGREEMENT TO PAY FOR SERVICES*
RELEASE OF INFORMATION*
COLLECTION OF ACCOUNT*

Main Office:
PALM HARBOR MRI
32615 US Hwy 19 North
Palm Harbor, FL 34684
Phone: 727.787.6900
Fax: 727.216.4789

FACILITIES

Palm Harbor MRI
Palm Harbor MRI – Wesley Chapel
Highland MRI (Lakeland)
Winter Haven MRI
Brandon MRI
Sarasota MRI
Brandenton MRI
Venice MRI
Venice MRI-Port Charlotte

MODALITIES

High Field MRI
Wide Bore HF MRI
High Field Open MRI
Arthrograms
MRA | MRV
MRCP
Diffusion Tensor (DTI)

Susceptibility Weighted (SWI)
NeuroQuant
CT Scan | CTA
Echocardiograms
Ultrasounds
X-Rays
DEXA – Bone Density
3D Mammography
Health Screenings

QUICK LINKS

Schedule Appointment
Physician Access
Patient Access
Attorney Access
Insurances Accepted
Exam Preparation
Pay Your Bill
Contact Us

Staff Resources

MRI Associates Attorney Portal
Effective immediately, all of our facilities are using the Clearpath platform to fulfill and process all legal requests. These requests include client records, reductions, all subpoenas, images and reports.

Please setup a login with Clearpath here:

Click Here to Access Clearpath

Why are we using Clearpath?

  • All requests for records, images, and billing must be done securely & digitally through the platform
  • Receive records including images digitally
  • Eliminate all mail, drop offs, pickups, paperwork, slow check payments
  • Reduced processing time
Click Here for More Information