If you have an upcoming appointment, please bring form and your health insurance cards with you to your appointment.
If you have already been seen and need to provide us information, please email or fax form along with a copy of your health insurance card (front and back) to Advanced Medical Imaging secure fax number (402) 484-4472 or email to email@example.com.
- When a healthcare services is necessary due to a work-related injury and the employer and/or employer’s insurance carrier accepts responsibility, the employer/carrier will be billed.·
- If payment is not received in 30 days, the patient may be asked to contact their employer or insurance carrier.
- If the employer/carrier denies the claim, the patient can have the claim billed to their health insurance carrier or will be billed directly for the services provided.
Third Party Liability
- If a patient is inured in an automobile accident, fall, etc., another party may have some legal responsibility for the injuries. Although this matter is between the injured party, their attorney , and the party responsible for the injury, the carrier provided will be billed on the patient’s behalf.·
- If the patient has a Medicare or Medicaid health plan, healthcare laws require that the liability carrier be billed first, then Medicare or the Medicaid health plan.·
- If the liability insurance carrier denies the claim or payment is not received in 30 days, the patient may be asked to contact the liability insurance. In the event the liability provider denies the claim, the patient can have the claim billed to their health insurance carrier or will be billed directly for the services provided.·
- If the patient carries Blue Cross Blue Shield (BCBS) insurance, BCBS requires providers bill BCBS for any liability claim. BCBS will subrogate with any 3rd party insurance carrier.