Click below to view and download the CMI Notice of Privacy Practices:

CMI Notice of Privacy Practices

  • RESPONSIBILITY FOR PAYMENT: I understand that I am personally financially responsible to CMI and MSN Healthcare Solutions for charges I have incurred that are not covered by the assignment of benefits. Notwithstanding that this bill may be submitted for insurance, patient and his/her legal/authorized representative(s) acknowledge responsibility for the balance shown on the patient statement for services rendered.

• LEGAL: Patient agrees that, in the event proceedings are instituted to collect monies due for services, that the patient waives all jurisdiction and venue requirements, and that venue and jurisdiction hall lie in Oneida County, in either Utica City Court or Supreme Court, or in Herkimer County in the Little Falls County Court or Supreme Court, and if the patient is found liable, also agree to be responsible for reasonable legal fees and costs related to such proceedings.

• PAYMENT @ TIME OF SERVICE (self-pay): I understand that I am required to pay 100% of my charges at time of service, unless I have a medical insurance carrier in which CMI and MSN participates with and can show proof (current valid insurance card) of such coverage or have made other arrangements with CMI and MSN Healthcare Solutions.

• NO FAULT/WORKER’S COMPENSATION: I understand that CMI and MSN Healthcare Solutions will bill NYS No Fault Insurance on my behalf. I understand that CMI and MSN will bill Workers Compensation Insurance on my behalf. If I fail to prosecute this claim or it is denied or disallowed I agree to assume full financial responsibility.

• PATIENT CONSENT: As outlined in the Notice of Privacy Practices provided to me and pursuant to New York State Public Health Law, I understand and authorize Cooperative Magnetic Imaging to use, obtain, and release my personal health information and/or medical records, including obtaining medical records from other providers, hospitals or other health-related facilities, for any aspects of my treatment and care, payment of services, and for operational purposes. I consent to receive text messages or phone calls sent by an automatic telephone dialing system.

• NOTICE OF PRIVACY PRACTICES: I acknowledge that I was offered a copy of the Cooperative Magnetic Imaging’s Notice of Privacy Practices as mandated by the HIPAA Privacy Rule.

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CMI Safety Questionnaire. 

Thank you so much for choosing CMI for your MRI!