CMI Registration Form

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Appointment Location

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Patient Name* This field is required.

First Name

Last Name

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Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Phone Number - Home* This field is required.

Area Code

Phone Number

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Employer Name

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Employer Address

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Phone Number - Work (optional)

Area Code

Phone Number

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E-mail (optional)

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Sex

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Date of Birth* This field is required.

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Marital Status

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Type of Insurance for today's appt (choose one)?* This field is required.

Commercial

Worker's Comp

No Fault

Other

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Insurance Company(s)

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Date of Injury:

Date

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

Yes

No

Other

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No Fault or Worker's Compensation Address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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No Fault or Worker's Compensation Phone:

Area Code

Phone Number

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No Fault or Worker's Compensation Policy#

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No Fault or Worker's Compensation Claim#

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

Yes

No

Other

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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

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Are you the Insurance Subscriber?* This field is required.

Yes

No

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Subscriber Name: * This field is required.

First Name

Last Name

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Pick One:* This field is required.

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Subscriber Date of Birth: * This field is required.

Date

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Emergency Contact:

First Name

Last Name

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Relationship

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Contact Number

Area Code

Phone Number

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Do you have Advanced Directives?* This field is required.

No

Yes

Unknown

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What type of Advanced Directives do you have (check all that apply):* This field is required.

Healthcare Proxy

Living Will

DNR

Other

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Would you like a copy of the CMI Notice of Privacy Practices?* This field is required.

YESNO

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

CMI Notice of Privacy Practices

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• 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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Signature

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