Accept Financial Responsibility
I understand and agree that, regardless of the insurance status, I am ultimately responsible for the balance of my
for any professional services rendered, including but not limited to collection agency fees and court costs. I
Northwest Radiology Network and agents to call my cell phone by auto dialer in order to collect any amount due. If
I have provided my personal email address, I authorize Northwest Radiology Network and agents to contact me via
email address. If after Northwest Radiology Network makes reasonable attempt to collect my balance due, I have not
responded by paying my account in full or by arranging for a payment plan, it will be turned over to a collection
The additional costs incurred by Northwest Radiology Network for this action will also be passed along to me.
Text Message Account Alerts
Text Message Account Alerts I authorize Northwest Radiology Network and agents to send text message appointment
or other communication to me on my provided cell phone number. I understand that text message charges from my cell
phone provider may apply.
I, as the parent or lawful guardian of this patient, authorize Northwest Radiology Network to render the ordered
well as any unforeseen treatment the staff deems necessary.
Northwest Radiology Network Patient Privacy Summary
Effective April 14, 2003
Northwest radiology Network (NWR) is committed to preserving the privacy of protected health information (PHI).
required by law to protect your medical information and to provide you with Notice describing:
How Medical Information About You May Be Used and Disclosed, and How You Can Access
NWR is required by law to have your written Consent before we use or disclose your medical information, for
of providing or arranging for your health care, the reimbursement of the care that we provide to you, and the
administrative activities supporting your treatment. Your signature on this Summary acknowledges that you
the Consent to release PHI arrangement.
As our patient, you have important rights relating to inspecting and copying medical information that we
or correcting that information, obtaining an accounting of disclosures of your medical information for which you
separate Authorization, requesting that we communicate with you confidentially requesting that we restrict certain
uses and disclosures of your health information, filing a formal complaint if you think your rights restrict
uses and disclosures of your health information, and filing a formal complaint if you think your rights have been
Your signature below acknowledges that you understand your patient rights in regard to PHI.
NWR may be subpoenaed for records or required by certain laws to use and disclose your medical information, for
purposes without your Consent or Authorization. Examples of such situations are described in the NWR Notice of
The Notice of Privacy Practices fully explains your patient rights and NWR obligations under the law. We may
our Notice from time to time. The effective date for the most current Notice in effect is shown on this
You have the right to receive a copy of our most current Notice in effect. Please ask a technologist, an office
employee or a billing staff employee who can provide you with a copy.
If you have any questions, concerns, or complaints about the Notice or your medical information, please contact:
Northwest Radiology Network - Privacy Officer
5901 Technology Center Drive
Indianapolis, Indiana 46278
317-328-5050 or 800-400-XRAY (9729)
“I request payment of authorized Medicare benefits be made to me or on my behalf to Northwest Radiology Network
for any services
furnished me by Northwest Radiology Network. I authorize any holder of medical information about me to release to
Health Care Financing Administration and its agents any information needed to determine these benefits or the
payable for related services.”