Atlantic Radiologic Imaging

               Patient Forms

Patient Registration Form    

Privacy Policy  

MRI Safey Screening for Patients  

Medical Records Release   

Medical Records Authorization Release Form  

      Patient Forms No-Fault only

No-Fault Assignment of Benefits  

Patient Registration Form No-Fault  

Referring Doctor Forms

General MRI Request From  

Insurance Pre-Certification Table  

ARI Orthopedic MRI Request Form  

ARI Podiatric MRI Request Form  

ARI Neurologic MRI Request Form  









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1. Patients should find out if their insurance policy or plan requires a pre-authorization or referral. If so, the patient should contact the insurance company and find out what is needed to obtain one. The phone number is usually found on the back of the insurance card.
   
2. Patients should give ARI OPEN MRI Center their complete insurance information, including insurance card, name and address of the insurance plan, claims payer, the ID number and group numbers, and the name of the policy holder or subscriber. Worker’s compensation, automobile, or personal injury cases require pre-authorization and, if applicable, the name and address of the patient’s attorney.

ARI MRI handles the billing for both services, and can be reached for billing questions at (914) 761-8287.

If a patient does not have medical insurance and/or is concerned about paying for the procedure, they should contact ARI OPEN MRI Center, we strive to help.

Ultimately, the patient is responsible for payment of the accounts, including any deductible and/or balance not covered by their insurance plan.