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New Patient Information Form

By agreeing to the terms of our secure forms, you will enter a secure area of our web site. RMI will not be held responsible in the event your electronic message is not transmitted due to technical problems related to this site or to the hosting server. All personal identifying information is encrypted and your message will not be internally or externally forwarded to other parties. The information will be used solely by RMI.

Fields marked with an * are required

Please provide for online access to your report.

Emergency Contact

Female Patients

Smoking Status/History

Background

Example: 5ft, 6 in, 180lbs

Allergies and Medications

Physician Information

INSURANCE INFORMATION

Medical or Additional Insurance

Injury/Accident/Liability Information

Auto Accident Related

WORK INJURY/ILLNESS RELATED

If any other party is responsible for payment of services provided by Regional Medical Imaging, please provide name and phone number to contact that third party below:

By checking the box below, I:

  • Certify that all information I have provided to Regional Medical Imaging is complete and accurate.
  • Request payment of authorized insured benefits to be made to Regional Medical Imaging for any services furnished to me. I understand that I am financially responsible for any and all services not covered or denied by insurance.
  • Authorize Regional Medical Imaging to release any medical information about me to my insurance company or responsible party, if injury related, that may be needed to determine benefits.
  • Consent for the procedure(s) to be performed. I have read, understand, and consent to the authorization and assignment stated above.
  • Give my express permission to Regional Medical Imaging and its affiliates or contractors to contact me for any given purpose at the current or any future numbers that are provided for my landline telephone, cellular telephone or any wireless device including the use of automated dialing equipment, prerecorded voice, or text messages.

 

secure lock -02This is a secure form.

By agreeing to the terms of our secure forms, you will enter a secure area of our web site. RMI will not be held responsible in the event your electronic message is not transmitted due to technical problems related to this site or to the hosting server. All personal identifying information is encrypted and your message will not be internally or externally forwarded to other parties. The information will be used solely by RMI.

Fields marked with an * are required

Please provide for online access to your report.

Emergency Contact

Female Patients

Smoking Status/History

Background

Example: 5ft, 6 in, 180lbs

Allergies and Medications

Physician Information

INSURANCE INFORMATION

Medical or Additional Insurance

Injury/Accident/Liability Information

Auto Accident Related

WORK INJURY/ILLNESS RELATED

If any other party is responsible for payment of services provided by Regional Medical Imaging, please provide name and phone number to contact that third party below:

By checking the box below, I:

  • Certify that all information I have provided to Regional Medical Imaging is complete and accurate.
  • Request payment of authorized insured benefits to be made to Regional Medical Imaging for any services furnished to me. I understand that I am financially responsible for any and all services not covered or denied by insurance.
  • Authorize Regional Medical Imaging to release any medical information about me to my insurance company or responsible party, if injury related, that may be needed to determine benefits.
  • Consent for the procedure(s) to be performed. I have read, understand, and consent to the authorization and assignment stated above.
  • Give my express permission to Regional Medical Imaging and its affiliates or contractors to contact me for any given purpose at the current or any future numbers that are provided for my landline telephone, cellular telephone or any wireless device including the use of automated dialing equipment, prerecorded voice, or text messages.

 

secure lock -02This is a secure form.

 

News Items & New Services

Discounts and Payment Plans

RMI provides options to help uninsured or underinsured patients manage the cost of medical imaging procedures.
More Information

CT Lung Cancer Screening

RMI now offers a test that can reduce the risk of lung cancer mortality in patients with a cigarette smoking history.
Read More
 

RMI Women's Services

Quality diagnostic and preventative care ... with a focus on women.
Women's Services
 
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