RADIOLOGICS Box Irving Texas by jennyyingdi


  P.O. Box 177128 * Irving, Texas 75017-7128 * 972/790-8236 * 1-800/972-8148 * FAX 972/399-6022

Referring Doctor / Clinic:              TEXAS HEALTHCARE NECK & BACK CLINICS, P A .

                                                       PATIENT INFORMATION

PATIENT'S N A M E :                                                                                             • MALE                • FEMALE

ADDRESS:                                                                                                        PHONE:

CITY:                                                                  STATE:                                  ZIP:

D A T E OF B I R T H :                                                 SS#:

WAS C O N D I T I O N R E L A T E D T O :   A ) Patient's employment             B) Auto Accident           C) Other

D A T E OF I N J U R Y :                                                         ATTORNEY:

Diagnosis: ( I C D #'S)

Patient's History: (recent trauma? suqjery? disease? previous diagnosis? weight gain or loss? irradiation therapy? etc.)

                                                         INSURED'S INFORMATION

• Self                • Spouse          • Child              • Employer          Employer Phone #:

Insured's Name:

Insured's I . D J :                                          Insured's Social Security #:                                 Claim #:

Insured's Address:                                                            City/State:                                      Zip:

                                                           BILLING      INFORMATION

Send Bill T o : (Check One)             1. Insurance Company                     2. Attorney                    3. Doctor


Address:                                                               City/State:                                           Zip:

Phone: (       )                                                       Fax: (        )

     I authorize the release of my x-rays/images to Radiologics for interpretation, understanding there is a separate fee for this service. I assign my
 insurance benefits and rights to payment to Radiologics and authorize them to their agents to bill and release information to my insurance company,
    attorney and any third-party payer. In the event that I receive payment for these services, I agree to promptly remit payment to Radiologics. If
   Radiologics does not receive a letter of protection/lien from my attorney, or does not receive a reply to my case status, then I understand I will be
  billed for the outstanding balance of my account. With my signature, I agree to the above provisions, I assign my insurance benefits and authorize
                                                               release of medical information.

Signature o f Patient or Insured                                       Date                                     Witness to Patient's Signature

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