CMI Registration Form

Appointment Location

Patient Name *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number - Home *

Area Code Phone Number

Please check all that apply.

Employed Full-time Employed Part-time Student Retired Disabled

Employer Name

Employer Address

Phone Number - Work (optional)

Area Code Phone Number

E-mail (optional)

Sex

Date of Birth *

Month Day Year

Marital Status

Type of Insurance for today's appt (choose one)? *

Commercial Worker's Comp No Fault

Insurance Company(s)

Date of Injury:

Date

Are you the insured person under this No-Fault claim?

Yes No

No Fault or Worker's Compensation Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

No Fault or Worker's Compensation Phone:

Area Code Phone Number

No Fault or Worker's Compensation Policy#

No Fault or Worker's Compensation Claim#

Is the condition solely the result of the auto accident listed above?

Yes No

I ("assigner") , hereby assign to Cooperative Magnetic Imaging ("assignee") all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance law. The Assignee hereby certifies that they have not received any payment from or on behalf of the assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on the Date of Injury indicated on this record, not withstanding any other agreement to the contrary. This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor. PLEASE CHOOSE ONE:

YES, I AGREE. NO, I DO NOT AGREE

Are you the Insurance Subscriber? *

Yes No

Subscriber Name: *

First Name Last Name

Pick One: *

Subscriber Date of Birth: *

Date

In case of emergency...

Emergency Contact:

First Name Last Name

Relationship

Contact Number

Area Code Phone Number

Do you have Advanced Directives? *

No Yes Unknown

What type of Advanced Directives do you have (check all that apply): *

Healthcare Proxy Living Will DNR

RESPONSIBILITY FOR PAYMENT: I understand that I am personally financially responsible to CW and Practice Management Services for charges I have incurred that are not covered by the assignment of benefits.

PAYMENT @ TIME OF SERVICE (self-pay): I understand that I am required to pay a 20% deposit on my charges at the time of services unless I have a medical insurance carrier in which CMI and PMS participate with and can show proof (current valid insurance card) of such coverage or have made other arrangements with CW and Practice Management Services.
NO-FAULT/WORKER’S COMPENSATION: I understand that CMI and PMS will bill NYS No-Fault Insurance on my behalf. I understand that CMI and PMS 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.
AUTHORIZATION: I hereby authorize the release to CMI and PMS any medical, insurance, or other information needed for this service or related medical condition or claim. I hereby authorize the release of medical information to my insurance carrier and referring provider. I hereby authorize my insurance carrier to direct the payment of my medical benefits to Practice Management Services for the services provided to me by the professional staff of CMI. I am aware of CMI's Notice of Privacy Practices and that I have the right to request further information as needed. This authorization may be conveyed by original signature or photocopy, which shall be as valid as the original.

1. 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.
2. 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.

I authorize CMI and Practice Management Services to obtain and/or release films and medical information necessary for treatment, payment, and /or healthcare operation. This authorization shall remain in effect until revoked by the patient.

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