Request Radiology Images

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By checking the box below, I understand that I am giving my authorization for Holland Hospital to use and/or disclose my protected Health information (PHI) as described above. This information to be used or disclosed pursuant to the authorization form may include information relating to: (1) Acquired immunodeficiency related complex syndrome (AIDS) or (2) Human immunodeficiency virus (HIV) infection, (3) Treatment for drug or alcohol abuse, (4) Behavioral health or psychiatric care, or (5) Communicable diseases and infectious disease, including sexually transmitted disease, venereal disease, hepatitis or tuberculosis. I understand that I may revoke this authorization at any time by notifying Holland Hospital in writing at Holland Hospital Medical Records Department, 602 Michigan Avenue, Holland Michigan 49423 of my intent to revoke this authorization. I understand that such a revocation will not have any effect on any information already used or disclosed by Holland Hospital before Holland Hospital received my written notice of revocation. If neither federal nor state privacy law apply to the recipient of the information, I understand that the information disclosed pursuant to the authorization may be re-disclosed by the recipient and no longer protected by federal or state privacy laws. This Authorization is voluntary and I may refuse to submit the Authorization Form. I understand that I am not required to submit this Authorization Form in exchange for the patient receiving treatment from Holland Hospital.
In order to process the above request, you must upload a copy of your Driver's License or State/Military Photo Identification Card.
One file only.
8 MB limit.
Allowed types: gif, jpg, jpeg, png.