Patient Forms

Thank you for choosing BMI!

Feel free to download Patient Forms prior to your visit:

For All Patients

• Patient Registration
• Medical History
• Privacy Practices Consent – HIPAA

MRI Patients:

• Patient Registration
• Medical History
• Privacy Practices Consent – HIPAA
• MRI Questionnaire
• Contrast Consent
• Pregnancy Consent

CT Scan Patients:

• Patient Registration
• Medical History
• Privacy Practices Consent – HIPAA
• Pregnancy Consent

Cardiac Score Patients:

• Patient Registration
• Medical History
• Privacy Practices Consent – HIPAA
• Cardiac Score Policy
• Pregnancy Consent

X-Ray Patients:

• Patient Registration
• Medical History
• Privacy Practices Consent – HIPAA
• Pregnancy Consent

DEXA Patients:

• Registration form
• HIPAA Form
• DEXA Agreement Form

MAMMOGRAM

FEMALE Mammogram Patients:

• Registration form
• HIPAA Form
• Breast Screening Questionnaire
• Breast Ultrasound Agreement
• If 50 years old or under: Pregnancy Consent

MALE Breast Imaging Patients:

• Registration Form
• HIPAA Form
• Male Breast Questionnaire
• Breast Ultrasound Agreement

New Patient

Thank you for choosing Bellevue Medical Imaging! You will need a referral form from your primary care physician. Below are links to the referral you will need.

• Bellevue Medical Imaging Referral
• Bellevue Women’s Imaging Referral

Getting ready for your exam

Bellevue Medical Imaging offers a range of services and provides you with the most up-to-date technological advances in diagnostic imaging.

In order for us to provide the best care for you, it is very important that you bring the following items to your visit:

• Photo ID
• A list of your current medications
• All prior imaging studies and reports
• Insurance card and information
• Pertinent medical history especially regarding prior surgical history
• Your request will be processed within 24 hours, during normal business hours. If you do not receive confirmation of your request within 48 hours, please contact our office by phone.

Pre-Authorizations

Our referral coordinating department specializes in pre-authorizations for you and your patients.

Insured AND Uninsured

We accept almost ALL insurances and offer the lowest uninsured rates to your patients..

Independent and Available

As an independent clinic, we are able to have a unique, close relationship with providers and patients.

We accept uninsured and insured patients.

No Insurance? No problem.

PARTICIPATING INSURERS & INFO