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Associates in Radiation Medicine
Medical Information & Insurance Consent

Please complete the online Medical Information & Insurance Consent Form. Required fields are identified with an "*" in the field name.  If you prefer to print out a copy and bring it to the office, please use the link in these instructions.  For new patients, please continue to the Patient HIPAA Consent Form to fill out or update your insurance information.

Medical Information & Insurance Consent

All information is encrypted

Please select your primary office location:
Charlotte Hall Office
Waldorf Office

Payment and Billing: I request that payment for all covered benefits related to any services provided to me by Associates in Radiation Medicine be made to Associates in Radiation Medicine. I understand that Associates in Radiation Medicine will bill the appropriate insurer or third-party payer as a courtesy to me when applicable. I authorize any holder of Protected Health Information to release to the Centers for Medicare and Medicaid Services and its agents, or my insurance company, any information necessary to determine available benefits. The presence of insurance does not define the benefits that may be available. Additionally, having insurance does not relieve me of my responsibility for payment. I agree to be accountable for paying charges for services rendered to me by Associates in Radiation Medicine that are not covered or paid for by Medicare or any other health insurance plan I might have. I hereby agree that if I receive payment directly from any health insurer or other payer, I will promptly forward the amount of such payment due on my account to Associates in Radiation Medicine or its authorized representative.

Please Note: Inaccurate insurance information and/or demographic details (D.O.B., address, phone number, social security number) may result in non-payment by certain insurance companies; in these cases, patients are responsible for all outstanding balances. I agree to provide all requested information and ensure its accuracy, understanding that I am financially responsible if payment is denied due to a lack of or incorrect information.

Please note: that you must submit the form to save any information.  Leaving the page will not save any of your insurance information.

Medical Information & Insurance Consent

All information is encrypted

Please select your primary office location:
Charlotte Hall Office
Waldorf Office

Payment and Billing: I request that payment for all covered benefits related to any services provided to me by Associates in Radiation Medicine be made to Associates in Radiation Medicine. I understand that Associates in Radiation Medicine will bill the appropriate insurer or third-party payer as a courtesy to me when applicable. I authorize any holder of Protected Health Information to release to the Centers for Medicare and Medicaid Services and its agents, or my insurance company, any information necessary to determine available benefits. The presence of insurance does not define the benefits that may be available. Additionally, having insurance does not relieve me of my responsibility for payment. I agree to be accountable for paying charges for services rendered to me by Associates in Radiation Medicine that are not covered or paid for by Medicare or any other health insurance plan I might have. I hereby agree that if I receive payment directly from any health insurer or other payer, I will promptly forward the amount of such payment due on my account to Associates in Radiation Medicine or its authorized representative.

Please Note: Inaccurate insurance information and/or demographic details (D.O.B., address, phone number, social security number) may result in non-payment by certain insurance companies; in these cases, patients are responsible for all outstanding balances. I agree to provide all requested information and ensure its accuracy, understanding that I am financially responsible if payment is denied due to a lack of or incorrect information.

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