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Please use this form to send us supporting documentation

Please use this form to send us supporting documentation

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  • Date of Birth Date of Birth * / /
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  • What type of document(s) are you needing to upload?

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  • Additional Information

  • Tricounty Radiology takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Tricounty Radiology to acquire certain data required to calculate your estimated financial responsibilities related to the respective imaging exam you have selected on this request form. * *
    Tricounty Radiology takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Tricounty Radiology to acquire certain data required to calculate your estimated financial responsibilities related to the respective imaging exam you have selected on this request form. *
  • *
    In the number 94847, what is the 5th digit?