The following items may be hazardous or may interfere with the MRI examination. Please indicate whether you have or have ever had any of the following.
Please read the following agreement carefully and provide your initials where indicated. Your signature at the bottom of this form will serve as your signature on this agreement.
I hereby agree to pay directly to Peach State Imaging PA (the "Practice") all amounts that may be due and owing for professional services rendered to me by the Practice and its medical providers. I further agree to assign any proceeds I receive from third parties to the Practice as necessary to pay the Practice's fees and charges for the medical care provided to me. I agree to direct any and all of my agents and/or personal representatives (e.g., guardian, attorney) to take all action(s) required to effectuate this assignment on my behalf.
I acknowledge that I am directly and fully responsible to the Practice for all medical bills associated with the services rendered to me by the Practice. I further understand that such payment is not contingent on any settlement, judgment, or verdict which I may eventually recover fees. I understand that this agreement tolls any laws that limit the time for the Practice to take action to collect amounts I may owe for the services provided and that my obligations to pay the same are not contingent on my receiving any recovery in my case. I further understand and agree this agreement is not a payment arrangement with respect to the satisfaction of my account whatsoever.
I acknowledge that the Practice's fees for its services are fair and reasonable.
I direct the Practice not to bill any of its fees or charges to any third party health insurance company (commercial insurance, worker's compensation, government program insurance) to which I am a member or beneficiary, or otherwise eligible to receive benefits. I represent that I will not (and my agents will not) submit any bills or claims to any such third party health insurance program for the Practice's services.
I agree that this Agreement is irrevocable. If there is a controversy or claim (each a "Dispute") arising from or otherwise relating to the terms of this agreement, I hereby consent and agree that such Dispute will be resolved through binding arbitration in the county and state where the Practice is located, with the American Arbitration Association ("AAA") before a single arbitrator. Such arbitrator shall award attorneys' fees and costs to the prevailing party.
I acknowledge and agree that, in accordance with the Health Insurance Portability and Accountability Act (HIPAA), the Practice may share my health information (including billing information) with my attorney and other personal representatives as necessary to ensure payment for the medical services provided to me by the Practice. Except for as provided above, all financial information, personal information, medical information, or information relating to this subject agreement is confidential and will only be disclosed as permitted or required by law.
I attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and have had the opportunity to ask questions. I have also informed the technologist whether I am pregnant or may be pregnant.