Appointment Scheduling Forms

CPT Codes

fid

OriginID_SessionStorage

OriginID_LocalStorage

Scheduling Preferences Required

Patient Information

Name*

First Last

Date of birth*

Gender*

Phone*

Email*

All important communication regarding appointments will be sent to this address. Double-check for accuracy.

Address*

Street Address Address Line 2 City State Zip Code

Other

Text Message Opt-in*

I agree to receive text messages for scheduling and appointment reminders. This is required to ensure timely communication regarding my appointments. No marketing text messages will be sent and you can opt-out by replying STOP.

Authorized Contact

Would you like to designate an authorized contact to discuss your scheduling and medical information on your behalf?

Benefits Code

Were you provided a benefits code by your plan or employer?

Authorized Contact

Authorized Contact Name*

Provide details for any individual authorized to discuss your appointment scheduling and medical records on your behalf.

Authorized Contact Phone*

Benefits Code

Benefits Referral Code

If you were provided a benefits referral code by your plan or employer, please enter it here

Member Benefit

As a valued member, you are entitled to a $10 off voucher for any lab test scheduled with our lab program, LaboratoryAssist. You will automatically receive the voucher via email once your appointment is completed.

Insurance Use

Do you plan to use your insurance for this appointment?

Yes, I plan to use insurance
No, I do not plan to use insurance
I’m not sure yet

RadiologyAssist is a self-pay program

We are unable to bill your insurance, however, you may use our services as a self-pay patient and can request reimbursement from your insurance after. RadiologyAssist will provide you with an invoice with codes and ids required by your insurance.

What insurance plan do you have?*

What type of plan?*

Appointment Scheduling Forms

Step 1 of 4 - Your info

Patient Information

Other

Authorized Contact

Benefits Code

Member Benefit

Insurance Use

Scheduling Preferences

Preferred Dates

Referral Information

Instructions

Medical History

Mammogram Screening Questions

MRI & CT Screening Questions

Communication

Acknowledgements

Patients

Providers

Organizations

Organizations

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