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Advanced Medical Imaging
Advanced Medical Imaging
9555 Seminole Blvd, Suite 101, Seminole, FL 33772
(727) 398-5999  ·  Fax: (727) 231-0772
Date: ___________________

Insurance & Financial Responsibility Agreement

Please read carefully and sign. This form is required for all patients.

Required — All Patients

1. Patient Information

2. Financial Policies

Insurance Billing

Advanced Medical Imaging will bill your insurance carrier as a courtesy. You are responsible for ensuring that our facility is in-network with your plan and that any required pre-authorization has been obtained by your referring physician. We do not guarantee insurance coverage or payment. The ultimate responsibility for payment rests with the patient (or guarantor), regardless of insurance status.

Copays, Deductibles & Coinsurance

Any copay, deductible, or coinsurance amount required by your insurance is due at the time of service. We accept cash, check, Visa, Mastercard, Discover, and American Express. We also offer payment plans — please ask our billing team.

Self-Pay Patients

Self-pay prices are due at the time of service. Ask about our self-pay discounts — our rates are up to 75% less than hospital system pricing. A payment plan may be available upon request.

Unpaid Balances

Balances not paid within 90 days of the statement date may be referred to a collection agency. A finance charge may be applied to past-due accounts. You may be responsible for collection fees and/or attorney fees.

Medicare Patients

Advanced Medical Imaging participates in the Medicare program. Medicare patients are responsible for the applicable deductible and 20% coinsurance unless covered by a secondary policy. We do not waive Medicare cost-sharing.

Cancellation Policy

We ask that you notify us at least 24 hours in advance if you need to cancel or reschedule your appointment. Late cancellations or no-shows may result in a $50 cancellation fee for MRI and CT appointments.

Assignment of Benefits

I hereby authorize payment of medical benefits to Advanced Medical Imaging for services rendered. I authorize Advanced Medical Imaging to release any medical information necessary to process my insurance claim.

3. Payment Method

4. Acknowledgment & Signature

By signing below, I acknowledge that I have read and understand the financial policies of Advanced Medical Imaging. I agree to pay all charges for services rendered to me or my dependent, regardless of insurance coverage. I authorize Advanced Medical Imaging to release information necessary for billing purposes and to receive payment directly from my insurance carrier.
Sign above
Questions about billing? Contact our billing department at (727) 398-5999.
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