Diagnostic Imaging Associates

Express Check In (1 of 3) Patient Information Form

Omega Imaging
Omega MRI
Omega Nuclear
Pike Creek
Brandywine
Glasgow
Womens Imaging Center

Date: xx/xx/xxxx
First Name: Middle: Last:
Birthdate: xx/xx/xxxx      Age:
Sex:      Marital Status:
Telephone:      Social Security:
Email Address:

Emergency Contact Information:

Name:
Date of Birth: xx/xx/xxxx
Address:
Telephone:

Spouse (or Parent) Employer Information:

Employer Name:
Address:
Telephone:

Physician Information:

Referring Physician Name:
Address:
Telephone:
Primary Care Physician:
Copy to Another Physician:

Primary Health Insurance Information:

Company Name:
Address:
Telephone:
ID/Policy #:
Group #:
Subscriber Name:
Effective date of coverage: xx/xx/xxxx

Secondary Health Insurance Information:

Company Name:
Address:
Telephone:
ID/Policy #:
Group #:
Suscriber Name:
Effective Date of Coverage: xx/xx/xxxx

Auto Accident or Work Injury Information:

Are you having this study as a result of:
An Auto Accident? yes no
An injury at work? yes no
Date of Accident or Injury: xx/xx/xxxx

Auto Accident/Workman’s Comp Information:

Company Name:
Address:
Claim Adjuster Name:
Telephone:
Claim Case #:

Attorney Information

Are you being represented by an attorney? yes no
Attorney Name:
Address:
Telephone:

Patient Authorization:
I authorize the release of any medical or other information necessary to process this claim. I authorize my insurance company to pay directly to DIAGNOSTIC IMAGING ASSOCIATES. I understand and agree that any unpaid balance not covered by my insurance will be paid by me.