Patient Information

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Patient’s Name:


Last:


First:


M.I:

MaleFemale


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Responsible party name if patient is minor:


Last:


First:


M.I:


Primary Insurance Information:

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Secondary Insurance Information:

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HIPAA Acknowledgement

I hereby acknowledge that I have been made aware that American Health Imaging, Inc. (AHI) has a privacy policy in place in accordance with the Health Insurance Portability Act of 1996 (HIPAA). As a patient, I acknowledge that AHI has a privacy policy in effect and has made this policy available to me. I am entitled to an additional copy of the privacy policy if I desire.

I authorize the release of any previous results or images in the event AHI is in need of them to help with the diagnosis of my procedure today. I permit a copy of this authorization to be used in place of the original. I understand and acknowledge that I am personally responsible for the services rendered at this facility. American Health Imaging, Inc. will bill my insurance carrier as a courtesy. In the event of non-payment, I understand I will be responsible for any outstanding balances.


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