Patient Information Form


Please enter the following information concerning your name and insurance information. Once you've completed this form, click "submit" and your information will be sent to United Radiology Group. Thanks.

 

Account Number (if available)
       
Patient Name
Last: First:
Middle:    
       
Contact Phone Numbers
Home: Work:
       
Miscelaneous Personal Information
Date of Birth: (ex: 9/18/80)
Sex:  M   F
Responsible Party: 
       
Address
Street:    
City:    
Zip:    
       
Primary Insurance
Primary Insurance:
Subscriber's Name:
Subscriber's Employer:
Insured's Date of Birth: (ex: 9/18/80)
Insurance Address:
ID #:
Group #:
   
Secondary Insurance (if available)
Secondary Insurance:
Subscriber's Name: 
Subscriber's Employer:
Insurance Address:
ID #:
Group #:
   
 

 

Please be advised that information transmitted over the internet (including e-mail) is not secure. If you forward information to our office through the internet or ask that we communicate with you by e-mail, you are assuming the security risk for that information.