Text Box: BERLAND IMAGING & MRI   774 N NEW BALLAS RD    ST LOUIS, MO  63141    314-567-1656

 

PATIENT LAST NAME

FIRST NAME

MIDDLE INITIAL

 

 

 

PRIMARY STREET ADDRESS

CITY/TOWN

STATE

ZIP CODE

  

 

 

 

HOME TELEPHONE NUMBER

DATE OF BIRTH

GENDER

PATIENT SOCIAL SECURITY NUMBER

 (              )                      -           

              /              /

    M       F

                     -              -

CELL PHONE NUMBER

EMAIL ADDRESS

 

                    

EMPLOYER NAME

EMPLOYER PHONE NUMBER

 

 (              )                -

EMPLOYER STREET ADDRESS

CITY/TOWN

STATE

ZIP CODE

 

 

 

 

EMERGENCY CONTACT NAME (not living at patient address)

PHONE NUMBER

RELATIONSHIP TO PATIENT

 

 (              )                      -          

 

WHICH DOCTOR SENT YOU HERE TODAY?

LIST ANY OTHER DOCTOR(s) WHO SHOULD RECEIVE A REPORT

  

 

WHAT SERVICE ARE YOU HAVING DONE TODAY?

o MRI   o CT   o MAMMOGRAPHY   o X-RAY  o ULTRASOUND    o FLUOROSCOPY   o BONE DENSITY  oOTHER:_____________

HAVE YOU EVER BEEN TO BERLAND PRIOR TO TODAY?

o YES               o NO

 HOW DID YOU HEAR ABOUT BERLAND?

o MY DOCTOR     o FRIENDS/FAMILY     o PHONE BOOK    o BEEN HERE BEFORE     o OTHER:_____________________

               

INSURANCE INFORMATION

PLEASE BE SURE TO BRING YOUR INSURANCE CARD(S) WITH YOU TO YOUR APPOINTMENT.

PRIMARY INSURANCE CARRIER NAME

 

INSURANCE MAILING ADDRESS

CITY/TOWN

STATE

ZIP CODE

  

 

 

 

POLICY #

GROUP #

EMPLOYER

 

 

 

POLICY HOLDER’S NAME

PT RELATIONSHIP TO POLICY HOLDER

POLICYHOLDER’S SOC SEC #

  

 

                        -               -

           

 ASSIGNMENT OF BENEFITS / MEDICAL RELEASE:   I authorize the release of any payment and medical information necessary to process this claim and related claims.  I request payment of benefits to BERLAND DIAGNOSTIC IMAGING CENTER OF CREVE COEUR who accepts assignment of benefits.  I understand that if my account is not paid when due, I will be responsible for all costs incurred in the collection process of my account.  I further understand that any unpaid balance will be reported to a credit bureau.

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 Patient or Authorized Signature                                                                                                                                                   Date