Open MRI - Ultrasound - Echocardiogram - EKG
Conscious sedation/anesthesia offered for adult and pediatric patients

 

Patient Demographic Information

DATE:   

Patient First Name:   Last Name:  

DOB:   SS #:     Gender: Male  Female 
Address:    Apt #: 
City:   State:   Zip Code: 
Home Phone:   Cell Phone:   Alt. Phone: 
Email Address: 

Insurance Information
Primary Insurance:   
Policy Holder's Name:   Relation to Patient: 
Policy Holder's D.O.B:     Policy Holder's S.S.# 
Policy #:   Group #: 

Secondary Insurance:   
Policy Holder's Name:   Relation to Patient: 
Policy Holder's D.O.B:     Policy Holder's S.S.# 
Policy #:   Group #: 

**IF YOU WOULD LIKE YOUR REPORT TO BE SENT TO ANOTHER PHYSICIAN, PLEASE LIST BELOW**

Pediatrician:   Phone:   Fax: 
PCP:  Phone:   Fax: 
Other:   Phone:   Fax: 


**Due to the nature of care at this facility, we do not accept any advance directives or instructions from health care surrogates or powers of attorney**

Assignment of Insurance Benefits
The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents.  I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and /or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. 
 hereby authorize 
  Name of Insured                                                                                       Name of Insurance Company

to pay and hereby assign directly to Dr. Allen Rothpearl and Jericho Specialty Imaging all benefits, if any, otherwise payable to me for his/her services as described on the attached forms.  I understand I am financially responsible for all charges incurred.  I further acknowledge that any insurance benefits, when received by and paid to Dr. Allen Rothpearl and Jericho Specialty Imaging, will be credited to my account, in accordance with the above said statement.

Authorized Signature of Subscriber     

Date: