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American Imaging Full Diagnostic Testing

Demo Day

Doctors Authorization Form

I, Doctor ; Practice Name do hereby authorize American Imaging, LLC to provide a Demo Day of Diagnostic Imaging testing for the insured patients I shall provide. I understand and agree there will be no charge to my practice or office in any way whatsoever.

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 will instruct my staff to submit the desired patient ordering forms within 24-48 hours from my past/current patients that may include existing conditions and/or to RULE-OUT suspected conditions. (Most all patients qualify for said testing.) NO Medicare or Medicaid.

I will bill out to each patient's insurance for consults to go over the reports from the board certified neurologists and radiologists. For each day of testing.

Authorized Signature: Date: October 17, 2019

Doctor Please provide the Contact Person in charge of submitting forms here:

Name: Title: Phone: Cell:

Dr's Email: Office Hours: Comments:

STEPS TO TAKE NOW

Provide us with at least six or more patient Certificates of Medical Necessity Ordering forms today if possible. Be sure to submit directly to us at the fax number below. We have added your Demo Day to our testing schedule and are making travel arrangements for our technicians at this time. We will call you shortly to firm up the details.

Fax to: 800-311-0632

Referring Agent Email: @doctorsprx.com American Imaging Approval Code:

I have screened this Dr. and Dr. is ready to go but asking questions I am not qualified to answer. Before confirming the time they need a call from American Imaging.

I will fax ample physician signed Patient Medical Necessity forms for insured patients to 800-311-0632 within 24 hours from submitting this Authorization for each day of testing desired. Multiple days of testing are available and compensated accordingly. (same week days must be consecutive). Practice discipline market exclusivity is based on first in market and ongoing testing.

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Fax to: 800-311-0632

American Imaging Full Diagnostic Testing

Demo Day

Doctors Authorization Form

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