Patient Forms The following forms are available for download as PDFs: Patient History Acknowledgement of Receipt of Notice of Privacy Practices Acknowledgement of Financial Responsibility Assignment of Benefits Non Covered Service Per Insurance Disclosure and Consent - Intravenous Contrast Injection Imaging Prescription Form Patient Preparation and Driving Directions

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64-Slice CT Scan, Body, Heart, and Vascular Imaging in Southern California
99 N La Cienega Blvd. • Suite 103 • Beverly Hills, CA • 310.623.1150

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