Authorization For Services
Authorization for Services
I authorize Element Medical Imaging (EMI) to provide the imaging services which have been ordered by my physician and/or representative of my physician. I willingly agree to cooperate with all reasonable requests of the technologists and radiologists conducting my exam. I understand my results will be sent to my referring physician. Results can be sent to other physicians at my request upon check in. My results may not be given to me over the phone but can be obtained by accessing the patient portal.
My Financial Responsibility
I understand that I am responsible for the prompt payment for services rendered. I agree to pay for services upon receipt of an invoice from EMI or affiliates. EMI will invoice me after my insurance processes the claim. I understand there is no 30-day billing cycle. All invoices are due upon receipt.
I understand that I may be asked to pay a portion of my payment at the time of service before filing with my insurance based upon an estimation of my deductible and co-insurance. I understand this is an estimate and could owe more or be given a refund after complete processing by my commercial insurance carrier. All co-pays are due at the date of service.
I agree to present my insurance card at each visit. This information is required to ensure that no change in benefits or carrier has occurred. I will notify EMI if my insurance carrier or policy has changed since my last visit if I am a returning patient. I understand that if my insurance on file is incorrect due to being canceled or otherwise not in effect, I will be billed directly and will be responsible for my bill.
Self-pay and Group billing:
If I am a self-pay patient or paying via a pre-determined contracted rate from a provider or facility, I understand that I will be required to pay the full contracted rate at the time of service. Discounts will not be provided.
I understand that for any worker’s compensation cases, appointments will only be made through the WC carrier, occupational medicine provider, TPA or case manager. Claim number and billing information is required prior to imaging. Auto accident cases require date of injury, claim number and billing information along with a contact and insurance company. I understand and agree that I will be financially responsible for medical services related to accident cases if insurance fails to pay in full.
Past due balance
: I understand I must completely pay all past due balance prior to any further services being rendered by EMI.
I understand that payment of authorized benefits be made on my behalf to EMI or physicians in the practice for any services rendered to me by that facility or their physicians. I authorize EMI to release to my insurance company or its representatives or its intermediary’s information needed to determine my benefits payable for related services.
Mammography Patients only:
I authorize the release of my prior breast imaging exams and related records to the radiologists at Element Medical Imaging for comparison.
I understand and agree to the above information. Additionally, I agree to permit EMI and their business associates to contact me, and all other responsible parties on my account, with an automated dialing device on our cell phone or other mobile device concerning any and all aspects of my account; financial, procedural or scheduling.
I agree if this account is not paid in full when due and EMI should retain an attorney or collection agency for collection, I agree to pay all costs of collection including reasonable interest, reasonable attorney’s fees (even if suit is filed) and reasonable collection agency fees.
(required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
If Guardian, Relationship to Patient