• Private patient payment form

    Diagnostic Imaging Limited, Lido de France, Jersey
  • CHARGE: FROM £730 per body part. Multiple parts may be charged at a reduced rate per scan depending on the scans.
    As a private patient, it is essential that you are aware of all charges relating to your care and we would ask that
    you contact the Diagnostic Imaging team (Tel: 01534 498538, Email: di@diagnosticimaging.je) to ascertain costs.

     

  • Personal details

  • Payment details

    Please tick appropriate box and provide ALL details as Applicable:
  • Terms & conditions

  • 1.As a private patient, it is essential that you are aware of all charges relating to your care and we would ask that you contact the Diagnostic Imaging team (Tel: 01534 498538, Email: di@diagnosticimaging.je) to ascertain costs.

    2. If a patient has private medical insurance, the contract is between Diagnostic Imaging Ltd and the patient. It is the patient's responsibility to ensure that each procedure and item of service is covered by their policy. The patient will be responsible for any shortfall from the insurer.

    3. If a patient does not have private medical insurance, the contract is directly between Diagnostic Imaging Ltd and the patient.

    4. For patients with private medical insurance, as a courtesy, we will submit the invoice direct to the insurer, but it remain the patient's responsibility to ensure their insurance company arranges payment to Diagnostic Imaging Ltd. Full payment is due within 30 days of the invoice date. For those patients privately insured, where the insurance company does not make full payment, the shortfall remains the responsibility of the patient and is to be paid within the 30 days deadline. Failure to pay the invoice in full will result in the matter being referred to a debt collection agency.

    5.. Data Protection: We are permitted by law to collect, use and share your medical information with other medical agencies/health professionals regarding the provision of your medical treatment. We will not sell, distribute or otherwise disclose your information without your consent, unless required or permitted to do so by law.

  • Release of Information to be signed by patient:

    I, the undersigned, agree with the above terms and conditions, and authorise any information regarding my treatment to be released by Diagnostic Imaging Limited to my insurance company/agent for the purpose of processing/authorising an insurance claim.

  • Date
     - -
  • Accounts Suite 2.1, Lido Medical Centre, St Saviour's Road, St Saviour, JE2 7LA

    Telephone: 01534 498538 Fax: 858223 Email: di@diagnosticimaging.je

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