Upload Document Tricounty
Please use this form to send us supporting documentation
Please use this form to send us supporting documentation
Your Information
Your Name
Your name
Your name
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First
Last
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Date of Birth
Date of Birth
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Preferred phone number
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Email address
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Location
Tricounty
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Date of Service
Date of Service
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Modality / Type of Exam
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MRI
CT
X-ray
Mammogram
Ultrasound
Bone Density
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What type of document(s) are you needing to upload?
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Total File(s) Upload limit is 2.8 MB,
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File types accepted: jpg, jpeg, png, gif, doc, docx, pdf, tif, tiff, txt, odt, xls, xlsx, rtf, txt, odt, heic, bmp, csv, ppt, pptx
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Doctor Order / Healthcare Provider Referral Form
Insurance Card
Implant and or Medical Device Card
Other
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Doctors Order / Healthcare Provider Referral Form
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Insurance Card
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Implant and or Medical Device Card
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Other Type of Document(s)
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Additional Information
Additional Comments you would like to share?
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. *
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In the number 94847, what is the 5th digit?
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