Company Name

First Name Middle Last

Date of Birth

Claim Type

Claim Number

Date of Loss

Location Name

Address

City ,

First Name
Last Name

Telephone Number

Email

Film Review Types

Please upload documents. Acceptable formats are PDF and TIF and DOC.

Additional Comments

Business Associate Agreement

  I accept the above terms and conditions.

I request the Atlantic Imaging Group, LLC to provide a remote second opinion for the above-named patient. I agree to provide my patient with copies of their medical records and any other relevant diagnostic reports or studies, particularly of the imaging studies already performed. I also understand I will receive a copy of the assessment and recommendation and will review it with the above-named patient as I deem appropriate. I also acknowledge that I am authorized in the state which the service was performed to make this request.

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