BILLING INFORMATION

Is your visit due to a WORK-RELATED INJURY?

Is your visit due to a MVA/PERSONAL INJURY CASE?

IF YES TO ONE OF THE QUESTIONS ABOVE, NOTIFY THE FRONT DESK PRIOR TO TESTING


IF NO, GIVE FRONT DESK YOUR INSURANCE CARD(S) AND ENTER THE FOLLOWING:

If PATIENT is not the subscriber, List subscriber D.O.B. and your relation to subscriber below

If PATIENT is not the subscriber, List subscriber D.O.B. and your relation to subscriber below

If PATIENT is not the subscriber, List subscriber D.O.B. and your relation to subscriber below


If you are a child of the subscriber, who is financially responsible for deductibles, coinsurance, and copays.

FAILURE TO GIVE THE CORRECT INFORMATION PRIOR TO TESTING WILL RESULT IN UNNECESSARY OUT- OF- POCKET COST FOR YOU (THE PATIENT).

E-Signature

Please sign electronically below.

Your browser does not support the signature
Submit Signature


Click submit and you hereby give consent to sign this document electronically.

Sending data