Massachusetts Form B PDF Details

The Massachusetts B form serves a crucial function within the realm of medical imaging, specifically at the Massachusetts General Hospital's renowned 3D Imaging Service. Situated in the heart of Boston, this facility offers advanced imaging services, including CT dental images, which are of paramount importance for various diagnostic and treatment planning purposes. This form essentially acts as a conduit for the authorization and release of these critical medical images, facilitating their transfer between healthcare providers or directly to the patient. It requires detailed information, such as the patient's name, date of birth, medical record number, and the specifics regarding the recipient of the images, be it a new dentist or the patient themselves. Additionally, it outlines the options for the delivery medium of these images, ranging from CDs to DICOM CDs or even prints, underscoring the flexibility in how these vital diagnostic tools can be received. A notable feature of this process is the necessity for the requesting party to provide payment details for shipping, indicating a streamlined process for the expedient delivery of these images. The form remains a testament to the intricate yet crucial operational details that underpin the delivery of healthcare, particularly in specialties requiring advanced diagnostic imaging.

QuestionAnswer
Form NameMassachusetts Form B
Form Length1 pages
Fillable?Yes
Fillable fields15
Avg. time to fill out3 min 15 sec
Other namesct_dental_form_ b massachusetts general hospital w 9 form

Form Preview Example

FORM B

R) MASSACHUSETTS

GENERAL HOSPITAL

IMAGING

3D Imaging Service

55 Fruit Street - Gray 267C

Boston, MA 02114

Telephone: (617) 724-3667

Fax: (617) 643-2992

Authorization for Release of CT Dental Images

Patient Name: ________________________________________________________

(print please)

Date of Birth: _________________________

Medical Record #: ______________________-

I hereby authorize Massachusetts General Hospital to furnish medical images from my image file.

NEW DENTISTS’S NAME: _______________________________________

DENTIST’S TELEPHONE#:_______________________________________

MAIL TO (CHECK ONE) D

PATIENT OR D

NEW DENTIST

MAILING ADDRESS:_______________________________________

_________________________________________

_________________________________________

Date of Study:__________

Simplant Version (Simplant Pro or Version 7 above)______________________________

Media Type: (CD or DICOM CD or Prints)______________________________________

Please call Lab at (617 724-3667) with FedEx or Credit Card # for Shipping

__________

_______________________________________

Date

Patient Signature

Please fax this form back to the 3D Imaging Lab at 617-643-2992, thank you.

Revised 5/16/11

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Enter the required data in the area Simplant Version Simplant Pro or, Media Type CD or DICOM CD or Prints, Please call Lab at with FedEx or, Date, Patient Signature, Please fax this form back to the D, and Revised.

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