Pre-Registration Form

Patient Pre-Registration Form

Thank you for choosing EPIC Imaging for your exam. This pre-registration form is designed to save you time on the day of your exam. It covers basic information about you and provides us with the names of the party or parties responsible for payment. Please complete and submit the form at least one day prior to your exam.

We will still need to copy your insurance card(s) on the day of the exam as well as ask you for your Doctors orders for verification purposes. Please be sure to alert our staff that you have pre-registered when you come in to assure you receive the benefit of pre-registering.

Required Fields

Patient Information

First Name:

Last Name:

Date of Birth:

Sex:

MALE FEMALE

Social Security Number:

Home Phone Number:

First Name of Referring Physician:

Last Name of Referring Physician:

Phone# of Referring Physician:

Spouse's Name:

Spouse's Employer:

Have you ever been a patient in an EPIC Imaging Center before?

YES NO UNKNOWN

Where is your current exam scheduled?

EPIC IMAGING|EAST
233 NE 102ND AVE.
PORTLAND

EPIC IMAGING|WEST
8950 SW NIMBUS AVE.
BEAVERTON

PORTLAND PET CENTER
143 NE 102ND AVE.
PORTLAND

Date of your exam:

Responsible Party Information
The responsible party is not your insurance company. That information is entered elsewhere. This is the name of the individual who is ultimately responsible for all charges. In the case of child, the responsible party would be the parent and, more specifically, the parent who lists the child on his or her insurance.

*	Name:
*	Street Address:
*	City:
*	State:
*	Zip:
*	Social Security Number:
*	Name of Employer:
*	Employer Phone Number:

*	Is your visit the result of a work related injury?	YES NO

*	Is your visit the result of an automobile injury?	YES NO

Patient's Primary Health Insurance Information
If your insurance information is incomplete, you will need to provide complete information when you arrive for your appointment. Please bring your insurance card to your appointment.

Name of Insurance Company:

Name of Insured:

Relationship to Insured:

Policy Number:

Group Number:

Group/Plan Name:

Insured's Date of Birth:

Insured's Social Security Number:

Insured's Employer Name:

Insurance Company Address:

City:

State:

Zip:

Secondary Health Insurance Company

	Name of Insurance Company:
	Name of Insured:
	Relationship to Insured:
	Policy Number:
	Group Number:
	Insurance Company Address:
	City:
	State:
	Zip:

	Is there another insurance company you would like us to bill?
		YES NO