Authorization for Records Release "*" indicates required fields 10/13/2024Name* First Last Email* DOB* MM slash DD slash YYYY MRN* S.S.N* To (Doctor/Hospital) Attn Phone Fax Consent* I hereby authorize the release of my previous imaging studies, records or copies of such and request that they are sent to: Palm Harbor MRI 32615 US Hwy 19 N Ste 4 Palm Harbor, FL 34684 Phone: 727-787-6900 Fax: 727-787-1892*Records Requested*