Patient Forms – Regional Medical Imaging (RMI)

REQUEST AN APPOINTMENT | PATIENT SURVEY | PATIENT REGISTRATION

Billing & Insurance

Patient Forms

Home | News | Careers | Contact Us

Patient Registration

Our online patient registration form provides an additional level of convenience to RMI patients. Completing this form prior to your appointment will help us expedite the registration process when you arrive for your exam. It also allows us to verify your insurance benefits and notify you of any co-pays or deductibles you may be responsible for.

An asterisk (*) indicates required information.

PATIENT INFORMATION
First Name*
Last Name*
Date of Birth*
Gender*
Address*
City*
State*
Zip Code*
Email*
Home Phone*
Alternate/Work Phone*
Referring Physician*
Primary Care Physician*
Any other doctor's you would like to receive a copy of this report
Do you have insurance?*	Yes No
	Please review our Financial Policy Acknowledgement
EMPLOYMENT INFORMATION
Employer
Employer Phone
EMERGENCY CONTACT (Do NOT use home phone)
Emergency Contact name
Emergency Contact Phone
Relationship
PRIMARY INSURANCE INFORMATION
Plan Name*
Subscriber ID #*
Group #*
Subscriber First Name*
Subscriber Last Name*
Subscriber Date of Birth*
Relationship*
SECONDARY INSURANCE INFORMATION
Plan Name
Subscriber ID #
Group #
Subscriber First Name
Subscriber Last Name
Subscriber Date of Birth
Relationship

Regional Medical Imaging, P.C. | 3346 Lennon Road, Flint, Michigan, 48507 | (810) 732-1919
Please email comments or questions regarding our website or services to comments@rmipc.net