Order Online

I AUTHORIZE PAYMENT (MEDICARE/INSURANCE) TO BE MADE EITHER TO ME OR, ON MY BEHALF, TO RADIANCE RADIOLOGY AND / OR THE INTERPRETING PHYSICIAN
FOR ANY MEDICAL SERVICES FURNISHED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION PERTAINING TO ME TO THE HEALTH CARE FINANCING
ADMINISTRATION OR OTHER INSURANCE'S AS NEEDED TO DETERMINE BENEFITS PAYABLE FOR SERVICES RENDERED, BALANCE DUE WILL ULTIMATELY BE MY
FINANCIAL RESPONSIBILITY.

I CONSENT TO THE REQUIRED PROCEDURE NECESSARY AS NOTED BY THE DOCTOR, IN FULL KNOWLEDGE THAT I AM EXPOSED TO RADIATION DURING AN X-RAY.