Appointment Forms & Insurance Information
Appointment Paperwork
Complete your paperwork online and submit it before your visit! After completing the form select the "Submit" button at the bottom of the form and your completed paperwork will be waiting for you and your signature upon your arrival.
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Patient Information Form - complete for all visits.
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MRI Assessment Form - complete if you are having a MRI.
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Bone Density Survey Form - complete if you are having a bone density screening.
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Medical Record Release Form - complete if you need your Medical Records released & are not having a new study completed.
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Hold Harmless for Transportation - complete only if Desert Rose Imaging Center is providing Transportation to and from our office.
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Patient Self Pay Form - complete if you are paying for your visit out of pocket. Print Version
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Work Comp Verification Form - complete if you are submitting a Work Comp Claim.
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Don't forget your insurance card and co-pay.
Check Insurance Providers Accepted List
Check to ensure that we accept your insurance. If you do not see your insurance provider listed here please call out office to see if we can accept your insurance (928) 681-3600 we likely can!
| AARP | Medsolutions |
| AEI | Mega Insurance Center |
| AHCCCS - Apipa Personal Care Plus | Mohave County |
| AHCCCS - Evercare | Motorola Medicare Share |
| AHCCCS - Evercare Select | Mountain States |
| AHCCCS - Health Choice | Multi-Plan (TNRN) |
| AHCCCS - Native American | Mutual of Omaha |
| AHCCCS - Phoenix Health Plan | myMatrixx (TNRN) |
| AHCCCS - QMB | National Provider Network (TNRN) |
| AIG | Native American - AHCCCS |
| Allstate Life Insurance | Network Synergy Group (NSG) (TNRN) |
| Ameriben | One Call Medical |
| American Family | Operating Engineers |
| American Republic | Pacificare |
| Apipa Personal Care Plus - AHCCCS | Peach Springs Indian Health Services |
| Arizona Benefit Options | Phoenix Health Plan - AHCCCS |
| Arizona Department of Economic Security | Physicians Mutual |
| Arizona Foundation for Medicare | Plan Vist Solutions, Inc (TNRN) |
| Arizona School Alliance | PMSI Inc (TNRN) |
| BCBS Anthem | Premier Healthcare Exchange (PHX) (TNRN) |
| BCBS Federal | Prime Health Services ( PHS) (TNRN) |
| BCBS of Arizona | Principal Life |
| Beechstreet (TNRN) | Progressive Auto |
| Benesight | Pyramid Life |
| BeniCorp | QMB - AHCCCS |
| Berkley Risk | QTC Medical Services |
| BNSF Railway | Railroad Medicare |
| Bridgestone | Royal Neighbors |
| Broadshire | SCF of Arizona Work Comp |
| Cambridge Insurance | SCF Premier |
| Capstone | Secure Horizon |
| Caremark Insurance | Sierra Spectrum |
| CC Firefighters Local | Southern Cal Pipe |
| Champ VA | Southwest Carpenters |
| Cigna | Southwest Service Administration |
| Clark County Firefighters | Southwire |
| Connecticut General Life | SRT Admin Inc |
| Coresource | State Risk Management |
| Coventry Health Care National Network (TNRN) | Summit |
| Crawford and Company | Superien Health |
| Definity Health | Teamsters Local 631 |
| Dept of Labor | The Loomis Company |
| Dept of Veterans | Three Rivers Provider Network (TRPN) (TNRN) |
| Desert Canyon | TNRN - InterGroup Services Corp |
| Devon Health Services Inc (DEVON) (TNRN) | TNRN - Beechstreet |
| Diagnostic Imaging Services (TNRN) | TNRN - Coventry Health Care National Network |
| Evercare | TNRN - Devon Health Services Inc (DEVON) |
| Evercare - AHCCCS | TNRN - Diagnostic Imaging Services |
| Evercare Select - AHCCCS | TNRN - Evolution Healthcare Systems |
| Evolution Healthcare Systems (TNRN) | TNRN - First Health Group |
| Farmer's Insurance | TNRN - Focus Healthcare Management (FOCUS) |
| First Health Group (TNRN) | TNRN - IGS Health Services, Inc. |
| Fiserv | TNRN - Independent Medical Systems Ltd. |
| FMH | TNRN - Integrated Health Plan |
| Focus Healthcare Management (FOCUS) (TNRN) | TNRN - Multi-Plan |
| Ford Motor Company | TNRN - myMatrixx |
| Frank Gates | TNRN - National Provider Network |
| Gallagher Bassett | TNRN - Network Synergy Group (NSG) |
| GEHA | TNRN - Plan Vist Solutions, Inc. |
| Gilsbar | TNRN - PMSI Inc. |
| Golden Rule | TNRN - Premier Healthcare Exchange (PHX) |
| Group and Pension | TNRN - Prime Health Services ( PHS) |
| Hartford Insurance | TNRN - Three Rivers Provider Network (TRPN) |
| Health Choice - AHCCCS | TNRN - US Managed Care Organization, Inc. |
| Health Net of Arizona | Travelers |
| Health Plan of Nevada | Tricare for Life |
| Humana | Trident Plan Administrators |
| IGS Health Services, Inc (TNRN) | Trustmark |
| Independent Medical Systems Ltd. (TNRN) | UHC |
| Integrated Health Plan (TNRN) | UMR |
| InterGroup Services Corp (TNRN) | Unicare |
| Key Health | United American |
| Liberty Mutual | US Managed Care Organization, Inc. (TNRN) |
| Lifewise Health | Veterans Administration |
| Mailhandlers | Wausau |
| Marquette Life | Western Teamsters |
| Maxim Insurance | Zenith Administration |
| Medicare |
Physician Forms
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Physician's Referral Form - This form is password protected please call our office for a password. This form is for Physicians only.
We want your experience at Desert Rose Imaging Center to be as pleasant as possible. Is there anything else we can do for you? info@desertroseimaging.com
If you have problems with the forms please download the latest version of Adobe Reader for FREE. You can also complete the form and print it and then bring the printed copy to the office with you.
