Patient Registration

  • Date Format: MM slash DD slash YYYY
  • Ordering Physician

  • Additional Physician

  • Primary Insurance

  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • I assign all medical insurance benefits to Montclair Radiology for all my visits.

    I have provided full and complete insurance information.
    > If my insurance denies payment due to incorrect information, I will be responsible for the payment of my bill.
    I agree to pay for all deductibles, co-insurance amounts, and co-payments, and all non-covered services.
    I authorize Montclair Radiology to release protected health information needed for processing of claims for payment as applicable.
    If my insurance plan will not assign benefits to Montclair Radiology, then I understand that I am responsible for payment of all charges, regardless of whether or not I am later reimbursed by my insurance plan.

    I understand and agree that if my insurance plan sends payment to me rather than Montclair Radiology, I will immediately endorse the check and forward to Montclair Radiology to be cashed and applied to my account.
    I have reviewed the above and agree that the information is accurate unless noted otherwise
  • Date Format: MM slash DD slash YYYY
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