Diagnostic Imaging Refund Status Check
Submit your details to check the status of your diagnostic imaging refund request.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Diagnostic Imaging Procedure
*
Please Select
MRI
CT Scan
Ultrasound
X-Ray
Other
Date of Imaging Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Imaging Facility Name
*
Refund Request Reference Number (if available)
Original Payment Method
*
Credit/Debit Card
Cash
Insurance
Other
Amount Requested for Refund (USD)
*
Reason for Refund Request
*
Additional Comments or Information (optional)
Check Refund Status
Should be Empty: