Medical Release Form
To assist you in obtaining the release of your medical records, please print out and use our medical release form.
When you are contacted by the Breastlink Patient Services Team, we can walk through the form together and answer any questions you may have.
Date:
This is to authorize:
Facility Name
Facility Address
Facility Phone
To release:
Medical records
Pathology slides and reports:
Date(s) of service
Procedure(s)
Breast Imaging films and reports
To: Breastlink Medical Group Inc.
Director of Patient Services
Patient’s name(printed):
Patient’s DOB:
Patient’s signature
Please send records to the relevant Breastlink Center:
Breastlink Medical Group Inc.
ATTN: Director of Patient Services
9900 Talbert Ave Suite 103
Fountain Valley CA, 92708
Phone (714)378-5011
fax (714)378-5051
Breastlink Medical Group Inc.
ATTN: Director of Patient Services
701 East 28th St. Suite 201
Long Beach, CA 90806
Phone (562)933-7820 fax (562)933-7819
Breastlink Medical Group Inc.
ATTN: Director of Patient Services
14650 Aviation Blvd. Suite 200
Hawthorne, CA 90250
Phone (310)539-2300 fax (310) 539-9185
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