PATIENT INFORMATION FORM

Fieldset

  • PLEASEPRESENTYOUR INSURANCE CARD OR INFORMATION EACH TIMEYOUVISITOUR OFFICE YOU AREPERSONALLY RESPONSIBLE FOR ANY CO-PAYAND/OR DEDUCTIBLE DUEATTIME OFSERVICE
 

PRIMARY INSURANCE

 

SECONDARY INSURANCE

  • I, the undersigned certify that (I or my dependent) have insurance coverage and agree to assign Arcadia Radiology Medical Group all insurance benefits for services rendered. I authorize the use and disclosure of all medical records necessary for the purpose to secure payment of services. I understand that I am financially responsible for all charges
  • I acknowledge receipt of Arcadia Radiology Medical Group’s Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Arcadia Radiology Medical Group and of my rights with respect to my health information. I have been provided the opportunity to discuss my concerns I may have regarding the privacy of my health information.
 

Verification