Do not fill out this form if your insurance is Federal Medicare.

Please note, in certain instances, DXA/ Bone Densitometry/ Bone Mineral Density exam may not be covered by your insurance plan. These include, but are not limited to, the following situations/ conditions and/or diagnosis:

• Screening for osteoporosis/ Rule out osteoporosis (as written on script)
• Loss of height
• Prior bone densitometry exam less than two years ago
• Patients under the age of 65
• Male patients

Your insurance carrier will be billed accordingly and may include, but are not limited to, any of the charges listed below. You will be responsible for any denial, copay, coinsurance and/or deductible applied to these services/billable to the patient:

DXA (Spine/ Hip/ IVA)	77085	$400.00
DXA (Spine/ Hip/ No IVA)	77080	$240.00
DXA (Spine/ Hip/ Wrist/ IVA)	77081/77085	$520.00
DXA (Spine/ Hip/ Wrist/ No IVA)	77080/77081	$360.00
DXA (Wrist)	77081	$120.00

Please sign below indicating you have read and understood the above information. If our prices change or this is modified in the future, you will be asked to sign a new sheet. Otherwise, your electronic signature below means you have read and understood our policies as stated regarding the DXA/ Bone Densitometry imaging studies you are having today and in the future. This signed notification will become a part of your permanent record at Weinstein Imaging Associates.

By submitting the information below, you are indicating that you have read and understand our billing policy.