PATIENT INSURANCE INFORMATION

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SUN RADIOLOGY

623-815-8200

623-815-8299

PATIENT INSURANCE INFORMATION

PRIMARY INSURANCE :

Name

Group ID

SUBSCRIBER’S NAME:

Relationship

SSN

Susbscriber’s Address

City

State

Zip

Phone Number

Email ID

SECONDARY INSURANCE:

I certify that above information is true and current. I certify that I have active insurance and is not terminated. I have checked with my insurance that Sun Radiology is in my network and my insurance has given prior authorization for the exam /services being performed today.
Failure to comply with above will result in non-payment by my insurance and I will be responsible for all payments for the exam/services being performed today.

Patient Name:

Patient Signature:

Signed on: