URPrecious Imaging Insurance Cost Estimation Request Form
Please fill out your personal and insurance details, select your imaging exam, and choose how you'd like our billing team to contact you.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Primary Insurance Information
Enter your primary insurance details below.
Primary Insurance Company Name
*
Primary Insurance Policy Number
*
Primary Insurance Group Number (if applicable)
Primary Insurance Subscriber First Name (if different from patient)
Primary Insurance Subscriber Last Name (if different from patient)
Date of Birth of Primary Insurance Subscriber (if different from patient)
-
Month
-
Day
Year
Date
Please upload clear photos of the front and back of your insurance card so we can verify your benefits, and provide best estimate for you. Otherwise, if unable or prefer not to upload, please call us at 602 878 7501 and ask for billing team associate to provide the additional details on your insurance card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Secondary Insurance Information (if applicable)
Enter your secondary insurance details below if you have secondary coverage.
Secondary Insurance Company Name
Secondary Insurance Policy Number
Secondary Insurance Group Number (if applicable)
Secondary Insurance Subscriber First Name(if different from patient)
Secondary Insurance Subscriber Last Name (if different from patient)
Date of Birth of Secondary Insurance Subscriber (if different from patient)
-
Month
-
Day
Year
Date
Upload Secondary Insurance Card (Front and Back)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Select Imaging Exam(s) Requested
*
Screening 3D Mammogram
Screening Contrast Enhanced 3D Mammogram
Diagnostic 3D Mammogram both breasts
Diagnostic 3D Mammogram of one breast
Diagnostic Contrast Enhanced 3D Mammogram (always performed bilateral)
3D Ultrasound of both breasts
3D Ultrasound of one breast
REMS Echolight Bone density / quality Ultrasound
Thyroid Ultrasound
Complete Abdominal Ultrasound
Pelvis Ultrasound
Neck Ultrasound
Carotid Ultrasound with CIMT
Ultrasound guided core needle biopsy
Stereotactic mammogram guided core needle biopsy
Fine needle aspiration of cyst
Fine needle biopsy of thyroid nodule
Remote consultation with radiologist (second opinion/cryoablation consult)
Breast cryoablation
Other
Please specify any other exams / additional details if needed
Preferred date for exams , if applicable
Additional comments or specific instructions for billing team
Preferred Method(s) for Billing Team Response
*
Email
Text Message
Phone Call
Staff Action Status
Please Select
New
Pending
Completed
Staff Notes
Submit
sysAccountName
sysAppointmentID
sysOrderID
sysPatientID
sysCareflowPrefillID
userrole
sysUserName
sysReportOutputTemplates
Should be Empty: