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Appointments
Services / Modalities
Contact Us
Physican Portal
Patient Portal
Attorney

Appointments
Services / Modalities
Contact Us

Menu

Appointments
Services / Modalities
Contact Us

Physican Portal
Patient Portal
Attorney Portal

Menu

Physican Portal
Patient Portal
Attorney Portal

Consent of Disclosure

"*" indicates required fields

07/27/2024

Name*

First Last

Email*

MRN*

DOB*

MM slash DD slash YYYY

Consent 1*

I have been provided access to MRI Associates Notice of Privacy Practices. I understand that I am entitled to a copy of these practices at my request.*

Consent 2*

I furthermore acknowledge that I have the right to designate access to my Protected Health Information (PHI) to anyone of my choosing. I hereby authorize disclosure of my PHI to the following individual(s)*

Authorized Individual 1

Authorized Individual 2

Authorized Individual 3

Consent 3*

I understand I may revoke this authorization at any time by submitting a written request to MRI Associates Privacy Officer, as per the office’s Notice of Privacy Practices.*

Consent 4*

I understand that by signing this authorization,this information will be used by MRI Associates to make determinations for the release of my PHI. I also understand this authorization will remain in effect until I request an update and/or amendment.*

OUR FACILITIES

PALM HARBOR MRI
32615 US HWY 19 North
Palm Harbor, FL 34684

727.787.6900 P | 727.787.1892 F

Monday – Friday: 7 am to 10 pm
Saturday – Sunday: 8 am to 7 pm (MRI only)

HIGHLAND MRI
2946 Lakeland Highlands Road
Lakeland, FL 33803

863.510.5944 P | 863.510.5939 F

Monday, Wednesday, Thursday:
7 am to 8 pm
Tuesday: 7 am to 7 pm
Friday: 7 am to 6 pm

WINTER HAVEN MRI
409 East Central Avenue
Winter Haven, FL 33880

863.294.0999 P | 863.294.0010 F

Monday – Friday: 7 am to 10 pm

BRANDON MRI
403 South Kings Avenue
Suite 200
Brandon, FL 33511

813.210.8995 P | 813.409.2914 F

Monday – Friday: 8 am to 5 pm
Extended Hours Available Upon Request

SARASOTA MRI
2 North Tuttle Avenue
Sarasota, FL 34237

941.951.1888 P | 941.951.1910 F

Monday – Friday: 7 am to 10 pm

BRADENTON MRI
5817 21st Avenue West
Suite B
Bradenton, FL 34209

941.567.4039 P | 941.567.4041 F

Monday – Friday: 8 am to 5 pm

VENICE MRI
1370 East Venice Avenue
Suite 101
Venice, FL 34285

941.484.6500 P | 941.484.6556 F

Monday – Friday: 8 am to 5 pm

VENICE MRI - Port Charlotte
21186 Olean Blvd.
Port Charlotte, FL 33952

941.289.0705 P | 941.237.5903 F

Monday – Friday: 8 am to 5 pm

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
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
DTI | SWI | TBI
NeuroQuant
CT Scan | CTA
Echocardiograms
Ultrasounds
X-Rays
DEXA – Bone Density
3D Mammography
Health Screenings

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