Welcome to Diagnostic Imaging Services of Idaho

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(208) 237-0977

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Check if patient is not a minor and responsible party is same as above

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Insurance Information

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Patients that have Medicare, Medicaid, Blue Cross or Blue Shield DO NOT need to fill in the address

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Secondary Insurance:

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Patients that have Medicare, Medicaid, Blue Cross or Blue Shield DO NOT need to fill in the address

Insurance Address:

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Assignment and Release

NON MEDICARE: I hereby assign my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any non-covered services. I authorize the physician to relase any information required to process this claim.

MEDICARE: I request that payment of authorized Medicare benefits be made wither to me or on my behalf to Diagnostic Imaging Services of Idaho for any services furnished to me by that practice. I authorize and holder of medical information about me to release to the Centers for Medicare and Medicaid Services, formally the Health Care Financing Administration and its agents any information to determine these benefits or the benefits payable for related services.

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Acknowledgment Notice of Privacy Practices

I acknowledge and agree that I have received and/or read a copy of Diagnostic Imaging Services of Idaho's Notice of Privacy Practices

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ACKNOWLEDGMENT OF INTEREST RATE CHARGES ON PAST DUE ACCOUNTS

Diagnostic Imaging Services of Idaho charges all patients an interest rate of 5.00% APR on past due amounts over 90 days. If your insurance has a deductible that hasn't been met this will apply to you. Interest will begin to accure 90 days after the date of service. If you have any questions about this policy or would like to set up a payment plan, call us at (208) 237-0977. Please sign below acknowledging that you have read and accept the interest rate terms as explained above.

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We appreciate being able to serve you!