Patient Info

Insurance Information

Please present card at check in

Assignment of Medical Benefits

I request that benefits be paid by my insurance or health plan (including Medicare) directly to the PROVIDER. If applicable, I understand that I will be responsible for any outstanding or unpaid balance on my account. Additionally I understand that I shall be responsible for any legal expenses incurred by BayView Radiology associated with collecting any unpaid balances.

Consent for Treatment

I AUTHORIZE THE Provider to furnish the necessary medical treatment or procedures, including diagnostic, x-rays and laboratory procedures, anesthesia, hospital services, drugs and supplies as may be ordered by the attending physician(s), his assistants or his designees. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of these diagnostic procedures or examinations.

Authorization for Release of Medical Records/Films

I authorize the release of reports and/or films from ANY facility/physicians office to BayView Radiology. I understand that: My right to healthcare treatment is not conditioned on this authorization. I may cancel this authorization at any time by submitting a written request to the address provided at the bottom of this form, except where a disclosure has already been made in reliance on my prior authorization. If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be re-disclosed. Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment information requires additional authorization. There may be a charge for the requested records.

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