Weinstein Imaging Associates

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Patient Forms

We would like you to fill out your forms electronically whenver possible. Please check for a text or email the day before your scheduled appointment.

If you'd like to fill out the following paper forms, please do so no earlier than one week before your appointment, since symptoms can change over time.

	All Patients (COMPLETE ALL 4 FORMS)
	Billing Policy
	Patient Information Form (If you're new to us or haven't updated the form in the past 3 yrs)
	Acknowledgement of Receipt of Notice of Privacy Practices
	Personal Representative Form (To designate an alternate contact person if we're unable to contact you)
	Breast Imaging Patients (COMPLETE BOTH FORMS)
	Breast Imaging Billing Policy
	Breast Imaging Questionnaire
	Other Patients (pick the appropriate tests)
	Pelvic or Obstetric Sonogram
	Abdomen or Kidney Sonogram
	Thyroid Sonogram
	Osteoporosis DXA Test Billing Policy (Do not fill out this form if your insurance is Federal Medicare)
	Osteoporosis DXA Test
	Transfer of Images
	If you have a scheduled appointment with us AND your last similar exam was done elsewhere, fill out this form to request records (This form may be printed and faxed directly to the other facility)
	Request that we transfer your records to another facility (This option is only if are going elsewhere for your next imaging test or your doctor needs our imaging pictures. Your doctor will automatically receive a report of your test results.)

For your information, please refer to our list of accepted insurance plans and our privacy policy.