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Request FILM REVIEW with Atlantic Imaging Group
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Insurance Carrier/Payer
Company Name
Patient Information
First Name
Middle
Last
Date of Birth
Claim Information
Claim Type
Claim Number
Date of Loss
Service Location Information
Location Name
Address
City
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About you
First Name
Last Name
Telephone Number
Email
Review Types
Film Review Types
Upload Document
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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Submit Film Request
Thank you for submitting Film request to Atlantic Imaging Group. If you have any questions, please call us at 888-340-5850.