702.759.8600 | WWW.DESERTRAD.COM
Patient Name: DOB:
Street Address: Apt. /Unit:
City: State: Zip Code:
Phone: Cell:
Responsible Party Name:
Primary Insurance: ID #:
Secondary Insurance: ID #:
I understand that authorized personnel from Desert Radiology may communicate with me regarding scheduling, follow-up on treatment
provided, educational information including newsletters as it relates to health-related products or services available at DR, or alternative
treatments, locations or providers. I agree to receive such communication via email at the email address provided below
Patient/Guardian Signature Date
This Financial Responsibility Acknowledgement will remain in effect for one year from the date of signature. Desert Radiology will bill your
insurance carrier for you. Patient/insured assigns all insurance benefits to Desert Radiology for services provided today. Patient/ insured
assumes and agrees to pay all applicable deductibles, coinsurances and co-pays. Patient/insured agrees to pay for all non- covered services
(preventive, screening or routine) that are not covered by the insurance company. Patient/Insured assumes responsibility for ensuring that
insurance approved laboratory is utilized. Patient/insured understands that all returned checks are subject to a return check fee of $25.00.
Please note that co-payment/deductible/coinsurance amounts quoted are estimates provided by your insurance carrier. You may receive a
bill for additional amounts due from your service. Patient/insured is advised that Desert Radiology is contracted with an outside billing
service. Imagine Pay will provide billing statements; they can be reached at 702-623-7568. Desert Radiology and or its billing/collections
representatives may contact you by phone at any number associated with your account, including wireless numbers, which may result in
charges to you. We may also contact you via text messaging or emails, using any email address you provided to us.
I further understand that it is my responsibility to ensure that laboratory approved by my insurance is used for any test/ biopsy results
and that I must follow up with my referring physician directly regarding my test/biopsy results.
Patient/Guardian Signature Date
_________________________________ _________________________________ ____________________________________
Patient/Insured Initials Date Patient/Insured Initials Date Patient/Insured Initials Date
_________________________________ _________________________________ ____________________________________
Patient/Insured Initials Date Patient/Insured Initials Date Patient/Insured Initials Date
click to sign
click to edit
click to sign
click to edit