Get Patient Information Form - Hartsdale Imaging

Filling out the Patient Information Form for Hartsdale Imaging online is a straightforward process. This guide will provide you with step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Patient Information Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your last name, first name, and middle initial (MI) in the designated fields to identify yourself.
3. Provide your date of birth to help verify your identity. This information is essential for medical records.
4. Enter your social security number (SS#) in the appropriate field if required. This might be necessary for insurance purposes.
5. Provide your home phone number, work phone number, and cell phone number as the primary contact methods.
6. For primary insurance information, if the policy holder is the same as the patient, check the box provided. Otherwise, fill in the policy holder's first and last name, date of birth, and their relationship to the guarantor.
7. Specify if you have secondary insurance by selecting yes or no. If you select yes, ensure to provide the insurance card to the secretary.
8. If applicable, provide the name and office phone of the second doctor who should receive a copy of your results.
9. Read the authorization and release section carefully, ensuring you understand the permission you are granting regarding your medical records.
10. Review all the information for accuracy before submission. Once confirmed, you can save changes, download, print, or share the form as needed.

Complete your Patient Information Form online today for a hassle-free experience.