Southwest Diagnostic Imaging Center: Welcome

Please fill out the following form completely prior to your scheduled appointment.
This information will be printed in our office and presented for your signature at your appointment.
*This information will be encrypted and held in a secure database until a member of our staff retrieves it.

Today's Date

Account Number

Patient Last Name

Legal First Name

Middle Name

Address

City		State		Zip Code
Date of Birth		Sex		SS Number

Home Phone

Work Phone

Employer

Emergency Contact:
Name		Relation		Phone

Referring Physician
Last Name		First Name

Insurance Information
Insurance	Policy Number	Group Number
Insured's Name	DOB	Insured's Employer

Secondary Insurance
Insurance	Policy Number	Group Number
Insured's Name	DOB	Insured's Employer

All Patients: Please Read and Sign the Following

I hereby authorize such procedures as deemed necessary to be performed on the above patient by Southwest
Diagnostic Imaging Center (SWDIC).

I authorize SWDIC, Southwest Imaging and Interventional Specialists, P.A. (SIIS), and Texas Neuroradiology, P.A. (TNR) to release any medical information necessary for diagnosis or payment of claims to any third party payor or physician.

I authorize payment of medical benefits to SWDIC, SIIS, and TNR for medical services performed.

I understand that in addition to my bill from SWDIC, I will also receive a bill for the interpretation of my x-rays from
SIIS and/or TNR. (Please refer to the “Billing Information” handout for more information.)

I acknowledge and agree that the physicians participating in my care at Southwest Diagnostic Imaging Center are
not employees, agents, or servants of Southwest Diagnostic Imaging Center. They are licensed physicians
engaged in the private practice of medicine. I acknowledge and agree that Southwest Diagnostic Imaging Center
is not responsible for the judgment or conduct of any physician who treats me or provides a professional service
to me. I acknowledge and understand that each physician is an independent contractor who is not an employee,
agent, or servant of Southwest Diagnostic Imaging Center.

I understand that, subject to Federal, State, and private insurance requirements, I may be required to pay all or a
portion of the fees for the services that SWDIC will render. I acknowledge that late payment may result in referral
to an outside agency, which may impose interest charges consistent with State law.

I have been given the opportunity to read and/or receive a copy of SWDIC’s Notice of Privacy Practices explaining
uses and disclosures of protected health information.

Patient Signature: ________________________________ Date: ____________________________
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