I, Doctor ; Practice Name ; Discipline do hereby authorize American Imaging to provide a Demo Day of In-Office Diagnostic Imaging testing for the insured patients I shall provide. I understand and agree most insured patients will qualify for testing one or multiple times per year and there will be no charge to my practice, office or insured patients for said testing whatsoever. NO Medicare – NO Medicaid.
American Imaging will provide all equipment required for said testing as well as a certified technician who will travel to my offices to provide said testing at no cost to the practice above.
I agree to provide a small private space in my facility with HIPAA compliant phone access for the transmission of all testing results to American Imaging.
I understand and agree that American Imaging is licensed and authorized to do the testing in all 50 U.S. states and due to the nature of the testing, there is no risk to the patient or the practitioner whatsoever. Latest State Of The Art Equipment used is same as testing equipment used in many top rated U.S. Hospitals.
Non-invasive testing may include, one or more of the following: Nerve Conduction Velocity; Evoked Potentials; Balance Testing-VNG; Ambulatory EEG; Routine EEG; General Ultrasound; Musculoskeletal Ultrasound.
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I understand the initial Paid Demo Day does not obligate either party. However, this is an opportunity for my practice to qualify to take full advantage of ongoing testing days, daily, weekly, monthly or periodically as appropriate. I understand I may use the testing to expand services offered in my office and expand practice revenues and may elect to become a testing center for other practitioners in my area as well.
I will instruct my staff to fax/email a minimum of 6, up to 20 insured Patient Medical Necessity Ordering Forms for the first day(s) of testing today, or, within 24 hours to accommodate the current travel schedules of those flying/driving into my area for the upcoming patient testing schedule in my market.
Doctor, please provide the contact person in charge of submitting forms here and take a minute to advise them of the time sensitive nature of our technicians need to make travel arrangements. We must have all forms in our office within 24 hours to allow for confirming insurance, scheduling and travel time.