THE IMAGING CENTER

REGISTRATION FORM

Section 1:

Patient Name:  
Street Address:  
City:  
State:   Zip:  
Date of Birth:   Social Security#:  
Gender:   Male   Female    
Marital Status:   Married   Single   Divorced   Widowed   Other:
Employer:     Full-Time   Part-Time   Retired
Employer Address:   Phone#:  
Relationship to Insured:   Self   Spouse   Child   Other:
Emergency Contact & Relationship:   Phone #:  
Referring Physician:  

If insurance is in a name other than the patient, please complete Section 2.

Section 2:

Insured's Name:  
Street Address:  
City:  
State:   Zip:  
Phone #:   Social Security #:   Date of Birth:  
Employer:     Full-Time   Part-Time   Retired
Employer Address:   Phone#:  

 

Section 3:                                                     Authorizations

I hereby authorize payment directly to The Imaging Center.  I understand that I am financially responsible for any balance that is not covered or is determined to be medically unnecessary by any insurance carriers or other parties that may have responsibility or liability for the service(s) rendered.  If my account becomes delinquent, I agree to pay all collection/attorney fees required in the collection thereof.  I also authorize the release of my medical records necessary to process my claim or to provide my medical treatment.  I authorize The Imaging Center to obtain information relating to previous x-rays that I have had.

Patient/Guardian Signature:   Date: