Registration Form

Please fill out the form below ahead of your appointment.

Registration Form (Internal)

Step 1 of 4

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Patient Information

Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Email(Required)

Enter Email Confirm Email

Date of Birth(Required)

Social Security Number(Required)

Sex(Required)

Male

Female

Emergency Contact Name(Required)

First Last

Image of ID

Please upload a picture of your driver's license or other approved ID.

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB.

Phone(Required)

Relationship(Required)

May we release medical information to your emergency contact person?(Required)

Yes

Physician Information

Referring Physician(Required)

First Last

Primary Care Physician

First Last

Preferred Pharmacy(Required)

Insurance Information

Primary Insurance(Required)

Subscriber's Name(Required)

First Last

Date of Birth(Required)

Policy ID #(Required)

Patient Relationship to Policyholder(Required)

Secondary Insurance

Subscriber's Name

First Last

Date of Birth

Policy ID #

Patient Relationship to Policyholder

Image of Insurance Card (front)

Please upload a picture of the FRONT of your insurance card.

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB.

Image of Insurance Card (back)

Please upload a picture of the BACK of your insurance card.

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB.

Insurance Authorization(Required)

I hereby authorize Commonwealth Radiology, P.C. to release necessary medical information to my insurance company(ies). I further authorize direct payment to the above entity from the above listed companies. I understand that I am responsible for obtaining referrals, if necessary, and paying any co-payments, or deductibles required by my Plan. I also understand that I may be responsible for the full amount in event of non-coverage determined by my Plan.

Medicare Authorization(Required)

I authorize the holder of medical or other information about me to release to the Social Security Administration of the intermediaries or carries any information for all Medicare claims. I assign the benefits payable for covered services to Commonwealth Radiology, P.C. and/or its physicians.

Patient Payment(Required)

I agree to pay in full by cash, check, credit card, or money order at or before the date of service, unless I qualify for financial assistance.

Medical History

Personal History(Required)

Please check any that apply.

Heart Disease

High Blood Pressure

High Cholesterol

Stroke

Diabetes

Cancer

None of these

What type of cancer?(Required)

Surgical History(Required)

Check any that apply.

Tonsils

Heart Surgery

Gastric Bypass

Gallbladder

Kidneys

Bowel

Uterus

Prostate

Other

None of these

If other, please explain.(Required)

Check any of the following that you use:(Required)

Tobacco

Alcohol

Neither of these

Number of packs per day:(Required)

Number of drinks per week:(Required)

Family History(Required)

Check any that have affected a family member.

Heart Disease

High Blood Pressure

High Cholesterol

Stroke

Diabetes

Cancer

None of these

Family member with heart disease:(Required)

Family member with high blood pressure:(Required)

Family member with high cholesterol:(Required)

Family member with stroke:(Required)

Family member with diabetes:(Required)

Family member with cancer:(Required)

Type of cancer:(Required)

Medications(Required)

Please list one per line. If none, type N/A.

Allergies(Required)

Please list one per line. If none, type N/A.

Have you recently experienced any of the following?(Required)

Check any that apply

Fevers

Chills

Unintended Weight Loss

Blurred Vision

Dry Mouth

Nasal Congestion

Palpitations

Chest Pain

Cough

Shortness of Breath

Pain with Deep Breathing

Nausea

Vomiting

Stomach Pain

Diarrhea

Constipation

Reflux

Burning with Urination

Urinary Frequency

Blood in the Urine

Blood in the Stool

Muscle Aches

Easy Bruising/Bleeding

Dizziness

Headache

Seizures

Depressed Mood

Hot Flashes

Other

None of these

If other, please explain.(Required)

Is there anything else you'd like to discuss with the physician?

Authorization for Treatment

I hereby authorize medical treatment by the physician, the clinical staff and technical employees assigned to my care.
I authorize my treating providers to order any ancillary services deemed necessary for my care and treatment.
I understand that I have the right and the opportunity to discuss alternative plans of treatment with my physician or other healthcare provider and to ask and have answered to my satisfaction any questions or concerns.
In the event that a healthcare worker is exposed to my blood or body fluid in a way which may transmit HIV (human immunodeficiency virus), hepatitis B virus, or hepatitis C virus, I consent to the testing of my blood and/or body fluids for these infections and the reporting of my test results to the health care worker who was exposed, as required by Virginia law.
I consent to the release of my prescription history from any pharmacy or drug monitoring agency to my physician.

Agreement(Required)

I have read, understand, and agree to the above terms.

Payment Arrangements

I agree to be responsible for payment of all services rendered to me or my dependents.
By signing this document, I authorize the assignment to the Medical Practice of all payments under any insurance benefits otherwise payable to me for the services provided under any insurance policy (hospitalization, major medical, workers' compensation, or any other insurance or benefit plan).
By signing this document, I authorize the release of my protected health information (PHI) to my insurance companies or other third party payors, including their representatives, as necessary to determine coverage or as required for review, quality improvement, and/or management.
I agree to pay, at the time of service, any required co-payments, co-insurance and deductibles, as well as charges for services not covered by my insurance.
I understand that all unpaid balances will be billed to my address on file with this office and that I am responsible for updating in advance.
I understand that there is a $35 charge for returned checks.
I understand that past due accounts will be referred to a collection agency and that I will be responsible for all collection charges, associated legal fees, and the full balance on my account.
By signing this document, I agree that photocopies of this document are as legally binding as the original.

Agreement(Required)

I have read, understand, and agree to the above terms.

Privacy and Disclosure

Our Notice of Privacy Practices (NPP) provides information about how we may use and disclose your personal health information. By signing below, you acknowledge that you have been provided access to a copy of our NPP.

Your Name(Required)

First Last

Relationship to Patient(Required)

Acknowledgement(Required)

I acknowledge that I have been provided access to the Notice of Privacy Practices.

Permission to Disclose Private Health Information

Please list the names of persons with whom we may share Private Health Information.

Name

First Last

Name

First Last

Name

First Last

Your Primary Phone Number(Required)

May we leave a voicemail if we cannot contact you at this number?(Required)

I give Commonwealth Radiology, P.C. permission to leave a voicemail if they cannot reach me at the above contact number

I DO NOT give Commonwealth Radiology, P.C. permission to leave a voicemail if they cannot reach me at the above contact number.

Consent(Required)

By agreeing below, I give permission to the person(s) listed above to receive Private Health Information or other authorization as listed in the comments section. I understand this form is legally binding and that I may revoke my authorization at any time by submitting by request to change, add, or terminate such permission in writing.

I agree.

General Info

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804-281-8534

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Commonwealth Interventional Radiology

Registration Form