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!
Physician Forms
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Physician's Referral or Patient Encounter 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.
