Documents/Forms/Notices
For Medical Record release requests from Rice Medical Center hospital, please complete the “Authorization for Release of Information” form below and email it to release@ricemedicalcenter.net or FAX it to (979) 234-3785.
For Medical Information release requests for Rice Medical Associates, please complete the “RMA Release of Information” form below and email it to rmarelease@ricemedicalcenter.net or FAX it to (979) 234-5994.
- RMA Auth to Disclose Protected Heath Information from RMA
- RMA Auth to Disclose Protected Health Information to RMA
Download forms to Acrobat Reader or some other PDF reader for a fillable version. Then please print and sign before submitting.
MRI Forms
Before entering the MR system room, you will need to fill out these forms in order for us to determine if it is safe for you to have an MRI.
Additionally, any individual that will be going with you in the MRI scanner room will be required to follow these same instructions and procedures including filling out the same forms.
If you would prefer to complete these forms in advance, please bring the completed forms with you when you register for your examination.
If you have questions or concerns, please discuss them with the MRI technologist or radiologist prior to the MRI examination.
- If your procedure requires contrast you will need to fill out the MRI Intravenous Contrast Consent Form as well as the MRI Contrast-NSF Worksheet.
- Non patients fill out the MRI Non patient screening MRI Non patient screening (Spanish).
- ALL MRI patients fill out the MR Safety Metal Checklist.
- MRI Medication Guide Gadavist
Our pledge to you…
We understand that medical and billing information about you is personal. We are committed to protecting the privacy of your medical and billing information. We created a designated record of the care and services you receive to provide quality care and to comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor. Your personal doctor may have different policies or Notices regarding the doctor’s use and disclosure of your medical and billing information created in the doctor’s office. We are required by law to:
- Keep medical and billing information about you private
- Give you this Notice of our legal duties and privacy practices with respect to your protected health information
- Follow the terms of the Notice currently in effect
Your Information. Your Rights. Our Responsibility.