1. CONSENT FOR DIAGNOSTIC PROCEDURE(S):

It is understood that the diagnostic procedure(s) ordered by my physician will be performed by Global Imaging and do hereby authorize and consent to such service.

2. RELEASE OF MEDICAL INFORMATION:

I hereby authorize Global Imaging to release any medical information regarding the services performed to my personal physician, insurance company, and or employer (in the event of a worker’s compensation injury).

3. INSURANCE FINANCIAL AGREEMENT:

A quote of benefits and/or authorization does not guarantee payment from your insurance companies. It is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. The undersigned hereby agrees to pay all charges not covered by the health nsurance company. Any balance not paid within 90 days after the date of service will be considered in default unless financial arrangements have been made with the business office.

4. HIPAA:

I acknowledge I have read and agree with the HIPAA policy. If for any reason I am unable to pick up my personal records, I understand Global Imaging office policy requires proof of family/friend identity to release my information.

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or otherwise as permitted by such regulations.

A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR THIS PURPOSE.

5. CONSENT TO EMAIL/TEXT:

I consent to receive text messages and emails from Global Imaging, LLP. I understand that this request to receive emails and text messages will apply to all future appointment reminders and updates.