Teleradiology Services. We will provide you with medical services such as diagnostic imaging, interventional radiology procedures and nuclear medicine testing. We do not provide primary care or emergency services.
Fees and Payments. You are responsible for paying all fees associated with the services provided at the time of service including copays, deductibles, and non-covered amounts as determined by your insurance provider. We accept cash, credit cards, checks and most major credit cards. Unpaid balances may be subject to collection fees.
Insurance. We will bill your insurance provider as a courtesy; however, the ultimate responsibility for all fees lies with you. You are responsible for verifying your coverage and obtaining any necessary referrals or pre-authorizations from your primary care physician prior to your appointment. Not all services are covered benefits under all insurance plans.
Cancellation Policy. Please notify us at least 24 hours in advance if you need to cancel or reschedule your appointment. Missed appointments or late cancellations may result in a fee. Repeated late cancellations or missed appointments may lead to termination of the patient-physician relationship.
Consent. I authorize the physicians and staff at M3 Teleradiology to provide medical care as deemed necessary based on the orders of my referring physician. I understand that I have the right to consent or refuse any proposed treatment or procedure.
Release of Information. I authorize the release of any medical or other information necessary to process insurance claims related to services provided at M3 Teleradiology.
Acknowledgment. I have read, understand and agree to the terms and conditions set forth in this document. I acknowledge that I have received information about patient rights and responsibilities, and have been given ample opportunity to ask questions and obtain any additional clarification needed. I understand that I will receive a copy of the terms and conditions upon request.