SHADES MOUNTAIN IMAGING
502 MONTGOMERY HWY, SUITE 101
VESTAVIA HILLS, AL 35216

Due to the HIPAA (Health Insurance Portability and Accountability Act) laws, we are required to have on file anyone in your family/friends whom you authorize us to give your medical record information if needed. If you don't want anyone to have this information besides you and your doctor, please put none. Otherwise, please list in the space provided. We WILL NOT give out any of your information, unless requested by you, to the people listed below. Thank you for choosing Shades Mountain Imaging for your radiological needs.

Patient Name:  ___________________	____________________________
Patient Date of Birth:  _______________
Patient Social Security Number:  _____  _____  _______

_______________________________________	_  _____________________	 
(Name)					         (Relationship)			
________________________________________  ______________________	
(Name)					         (Relationship)			
________________________________________  ______________________	 
(Name)					         (Relationship)			

X_____________________________	____________
   Signature of Patient or Legal Guardian	Date