Patient Insurance Information

Patient Name

Date of Birth

PRIMARY INSURANCE

Name

Group ID

Subscriber's Name

Relationship

SSN

Subscriber's Address

City

State

Phone Number

Email ID

SECONDARY INSURANCE

Name

Group ID

I certify that the above information is true and current. I certify that I have active insurance and it 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 the above will result in non-payment by my insurance, and I will be responsible for all payments for the exam/services being performed today.

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