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  • AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Date of Birth
    Date of Birth: I AUTHORIZE VALLEY MRI AND RADIOLOGY INC TO RELEASE MY MEDICAL RECORDS TO:
  • PATIENT REGISTRATION - valleymri. com
    Non-disclosure of Patient Demographics information: I hereby decline to provide my race, ethnicity, smoking status, and preferred language to Valley MRI And Radiology Inc
  • 48 HOUR NOTICE - valleymri. com
    Any patient has the right to request medical records All efforts will be made to handle each request in a timely manner Due to patient load, privacy issues and obtaining accurate information, we will require 48 HOUR NOTICE to process your request All requests must be made in writing with specific items requested
  • FINANCIAL POLICY PATIENT: DATE: known - valleymri. com
    Self-Pay Patients: Full cash payments are expected at time of service We will not bill insurance at a later date once cash pay has been accepted Patients are required to sign a form on Valley MRI And Radiology Inc ’s self-pay policy
  • PATIENT NAME: PRIVACY POLICY - valleymri. com
    A copy of this assignment is to be considered as valid as the original If I receive an insurance payment directly, I agree to make full payment immediately to Valley MRI And Radiology Inc I understand that in the event my insurance company denies this claim, I will be held financially responsible for all charges when applicable





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