Online Check In
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. Don't forget your insurance card and co-pay.
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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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Patient Self Pay Form - complete if you are paying for your visit out of pocket.
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Patient Info Release From - complete if you need your Medical Records released & are not having a new study completed.
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Work Comp Verification Form - complete if you are submitting a Work Comp Claim.
Physician Forms
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Physician Order Form (call for password)
Insurance - Accepted Insurance Brochure
Please call us if you do not see your insurance on our list.
| ADIN Healthcare LLC |
| AETNA - PPO, Choice POS II, Open Access |
| Ameriben/IEC Group |
| America First Insurance (Div of Liberty Mutual) |
| American Republic Insurance Company |
| BCBS - of KC, Preferred Care Blue, Blue Advantage KC, Blue Care, Blue Care KC, Care Team, Federal Employee PPO, Hallmark |
| Beech Street Corporation (TNRN) |
| Bunch & Associates |
| Cambridge Integrated |
| Care Improvement Plus |
| Cigna PPO |
| CMHF |
| Continental Life Insurance |
| Coventry Health Care + PPO (Health Care USA) |
| Coventry Health Care National Network (TNRN) |
| Evolutions Healthcare Systems (TNRN) |
| First Health Group Corporation (TNRN) |
| First Health Plan |
| Fiserv Health AETNA |
| Fiserv Health PHCS |
| FMH Benefit Services |
| Freedom Network Select |
| Galaxy |
| Gallagher Bassett |
| Gened |
| Great West Casualty |
| Hartford Insurance |
| Health Care Preferred |
| Health Choice PPO |
| Healthlink/Freedom Network |
| Humana Health Care – HMO, PPO, Gold Plus |
| Independent Medical Systems (TNRN) |
| Integrated Health Plan (TNRN) |
| Key Health Lien Solutions |
| Liberty Mutual |
| MDM/Diatri |
| Med Solutions |
| Medicaid |
| Medicare |
| Medicare Railroad |
| Meritain Health |
| MO Health Net (Medicaid) - MRI may require pre-certification |
| MultiPlan, Inc. (TNRN) |
| myMatrixx (TNRN) |
| NIA/Magellan |
| NovaPro Risk Solutions |
| One Call Medical |
| PHCS (Private Health Care Systems) |
| PHP (Preferred Health Professionals) |
| Premier Health Insurance Co |
| Prime Health Services, Inc. (TNRN) |
| Pyramid Life Insurance |
| Sioux Valley Health Plan |
| Sterling Investors Life |
| Tech Health |
| TNRN (The National Radiology Network) |
| Triad Group |
| Tricare - Tricare West Region, Tricare for Life |
| Unicare |
| Union Security Insurance |
| United Health Care – HMO, PPO, Railroad Employees, TNRN UHC |
| UPREHS - Union Pacific Railroad Employees Health Systems |
| USA Managed Care Organization (TNRN) |
| Work Comp (all plans) |
*Some plans may require pre authorization.
**All work comp insurance accepted.
Our billing office is happy to assist with any questions or concerns - call (816) 268-4067 or email billing@maplecrestimaging.com.
Application for Employment
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MCIC Employment Application - complete online, print, sign and return.
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.
