Dakota Radiology - Forms & Documents

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Forms & Documents

Patient Forms

To view the forms listed below, you will need Adobe Reader.

You may download Adobe Reader for free at www.adobe.com.

Medical Records Release Form [pdf]

Please FAX completed form to Records Management at (605) 342-3930.

Notice of Privacy Practices [pdf]

CD Viewer Guide

Please note that the digital viewer burned on to the CD with your DICOM images is not compatible with Microsoft Vista. The following guide may help with the viewer that is loaded on the CD.

CD Viewer Guide [pdf]

Referral Form

Referral Form [pdf]

Mobile Mammography Site Forms

Authorization to File Insurance [pdf]

Authorization to Release PHI [pdf]

MagSheet [pdf]

Patient Demographics [pdf]

Film Release Form [pdf]