A+ Mobile Ultrasound Services

Registration

Registration Form

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ordering Provider

Type of Insurance

If WC or MVA, Please list date of inujury

YYYY

Insurance Carrier

Policy # or Claim #

Group #

The above information is true to the best of my knowledge. I have been informed and educated on the particular exam that is to be performed. I give consent to perform the exam. I give consent to be video and audio recorded for security. I authorize my insurance benefits be paid directly to the facility. I understand that I am financially responsible for any balance including, but not limited to, any funds applied to deductible, coinsurance or denied altogether by insurance. I authorize A+ Mobile Ultrasound Services, or insurance company to release any information required to process my claims.

Electronic Signature - By typing my name below, I attest that I acknowledge and accept the above.