General Registration

  • Authorization for Care and Release of Health Information

  • I authorize the medical facility below to release my information and the films and reports listed below to Advanced Imaging for the completion of my study.
  • Medical Facility
  • Previous Films & Reports
  • This authorization for release of information is valid for 12 months from the date of signature, unless revoked by written notice to the providing institution. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand that once the information is disclosed pursuant to this authorization, the recipient may re-disclose it and the authorization will not affect my ability to obtain treatment, receive payment, or eligibility for benefits unless allowed by law.I grant permission to the employees of Advanced Imaging of Port Charlotte to render care to me and expedite the orders of the physicians and/or physician extender. I further authorize release of this information to other healthcare providers associated with my care.
  • I also permit these addition person(s) to discuss my medical record or billing information.
  • I authorize Advanced Imaging to furnish information to insurance carriers concerning my care. I agree to pay Advanced Imaging for all services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by my insurance and if I have not secured appropriate authorizations and otherwise complied with the terms of my benefit plan, there may be a decrease or no coverage at all for services rendered at Advanced Imaging. For self-pay patients, I also understand that I am responsible for all services rendered to my dependents or myself. Full co-pays and self-pay charges are due at the time of service. Outstanding balances unpaid after 90 days will be assessed a billing fee of $15.00. Outstanding balances transferred to collections will be assessed additional fees to equal 30% of balance.
  • Please type your signature in the box above to acknowledge acceptance of the above agreement.

  • Email Authorization

  • I hereby authorize Advanced Imaging of Port Charlotte to email me at the address I enter below with current practice updates whenever possible. I understand that Advanced Imaging of Port Charlotte will not share my email address with any other persons or agencies. This authorization will remain in effect until I revoke this authorization in writing.
  • Please type your signature in the box above to acknowledge acceptance of the email authorization agreement.

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • Your name and signature on this section indicates that you have received a copy of Advanced Imaging’s Notice of Privacy Practices on the date indicated. If you have any questions regarding the information in our Notice of Privacy Practices, please do not hesitate to contact our Patient Privacy Officer at 941-235-4646.
  • Please type your signature in the box above to acknowledge your receipt of Notice of Privacy Practices.
  • If this form is being completed by a patient representative, please enter your name above and type your signature into the box below.