Male Female



M     S    W    D
Yes     No

W/C     MVA    Othre

Yes     No

Yes     No
Full-time     Part-time     Ret



: (cardholder: child/spouse)

 
  
   Male Female



Yes     No
Full-time     Part-time     Ret



(PLEASE GIVE INSURANCE CARD TO RECEPTIONIST)

 
  
  


Male     Female    


Patient     Mother     Fathe     Other     (Specify)   
: (PLEASE GIVE INSURANCE CARD TO RECEPTIONIST)

 
  
  


Male     Female    


Patient     Mother     Fathe     Other     (Specify)   
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I understand that Diagnostic Radiology Center of the Treasure Coast will not disclose any medical information about me to anyone except my physician, my insurance company or me with exception of the person I have indicated. I hereby give permission allowing to receive medical records and radiology films on my behalf.
Copy of HIPAA Privacy Policy and Consent to Use or Disclose Information for Treatment, Payment or Healthcare Operations, available upon request)

I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

 
  
  

ASSIGNMENT OF INSURANCE BENEFITS
I understand that I am financially responsible for any medical treatment rendered to me by Ajay K Goyal, MD and/or Diagnostic Radiology Center of the Treasure Coast. This includes any monies not paid by my insurance and which my insurance company deems my responsibility.
I authorize payment of medical benefits due me to be paid directly to Ajay K. Goyal, MD, dba Diagnostic Radiology Center of the Treasure Coast for services rendered by Ajay K Goyal, MD or his staff.


WE ARE A FILMLESS RADIOLOGY CENTER AND THEREFORE WE NEED 24 HOURS NOTICE TO PRINT YOUR FILMS. THESE FILMS ARE YOURS TO KEEP.
THERE IS NO CHARGE FOR THE FIRST SET OF FILMS YOU RECEIVE, BUT IF A SECOND SET IS REQUESTED, THERE IS A FEE OF $10.00 PER SHEET.

I accept to above all terms and condition