Imaging De-ID Request Form

Use this form for all imaging de-identification requests, including those for:

  • Research
  • Education/conferences
  • Manuscript submission
  • Clinical use

Please enter your email address. If you do not have an "@hitchcock.org" email address, you must ALSO provide the email address of your DH supervisor, education coordinator, or research collaborator.

Purpose of de-ID request*
Is this study IRB approved?*
Is the research protocol registered in OnCore?*
Is this a clinical trial?*
Does the research sponsor require imaging for treatment planning?*
Request is for:
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Do you need us to maintain the *original* DATE OF EXAM when we process the imaging?*
  • Turnaround time for 1-5 exams is 2 business days
  • Turnaround time for 6-10 exams is 3 business days
  • Turnaround time for 11-20 exams is 5 business days
  • > 20 exams, we will contact you regarding delivery date


If you require turnaround in less than 2 days, you must email us at <image-deid-team@hitchcock.org> to request an exception.

Our ability to fulfill such requests is based on staff availability.



Replacement value will appear in Last Name only unless otherwise specified.


Note: If a replacement value is not provided, Patient Name will be randomly anonymized.

Note: If a replacement value is not provided, Patient MRN will be randomly anonymized.

Note: If a replacement value is not provided, Patient DOB will be randomly anonymized.


Example: MRI Brain W/O & W Contrast

Do you have additional exams requiring de-identification for this same patient?

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Provide the following information for each additional exam:

Date of Exam | Exam Name | Imaging Accession #

Please upload an excel or csv file with the following columns:


Patient Name | MRN | DOB | Patient Study ID | Date of Exam | Exam Name | Imaging Accession #

Drag and drop files here or

Please provide any details we need to process your request. We will contact you if we have questions.

By checking this box, you acknowledge the de-identified imaging associated with this ticket will be deleted from the server after 30 days.

We will perform internal Quality Control (QC) procedures to ensure all images are appropriately de-identified. Our procedures do not eliminate the requestor's responsibility to comply with institutional, federal, and international (if applicable) data privacy laws and standards.


Please check this box to acknowledge your responsibilities regarding data privacy laws and standards: