Image Service Center


  • A signed Release and Authorization Form is Required for ALL Images and Medical Reports.
  • Download and Print the form here: Authorization to Release Images (PDF).
  • Please fax or email a release form to 617-724-0264 / imageservicecenter@mgb.org.
  • Please make a note of the Reference Number when calling for information regarding your request.
  • For Mammogram orders, unless otherwise requested by your physician, we will send images from the two previous exams in addition to the images from your most recent visit.
PATIENT INFORMATION
MGH MRN
Name
DOB
Address
City
State
Zip
Day Phone
Email
PLEASE SPECIFY DATE(S) AND TYPE(S) OF STUDIES

*Please be as specific with dates as possible. If you cannot provide exact dates, month and year will be accepted. Contact the Image Service Center if you are unable to provide any specifics.


SHIPPING ADDRESS: (Choose one of the following)



Name
Address1
Address2
City
State
Zip
SHIPPING METHOD: (Choose one of the following)

* For FedEx and UPS, Please call (617) 726-1798