Phone number: (780) 486-8104
Monday-Friday
SUREHIRE WILL NOT BE RESPONSIBLE FOR CHARGES INCURRED BY CLINIC OTHER THAN THE ONE LISTED.
CLINIC IS TO COMPLETE ONE P.A SCREEN ONLY.REASON FOR TESTING: R/O CHEST PATHOLOGY
|
Chest X- Ray Referral |
| Insight Leduc | Clinic Hours: 8:00am-5:00pm |
| Address: 5307 50 Avenue, Leduc, AB, T9E 6T2 Phone number: (780) 486-8104 |
**Walk In Basis** Monday-Friday |
|
SUREHIRE WILL NOT BE RESPONSIBLE FOR CHARGES INCURRED BY CLINIC OTHER THAN THE ONE LISTED. CLINIC IS TO COMPLETE ONE P.A SCREEN ONLY.REASON FOR TESTING: R/O CHEST PATHOLOGY |
|
From:
SureHire Inc.
Suite 8726 - 1000 Airport Road
Edmonton International Airport, AB T9E 0V3
Ph: 1.866.944.4473
Fx: 1.877.500.2620
Date:
Please accept the following referral for:
Date of Birth:
Please ensure that X-Rays are completed within 5 days of receiving this referral.
Immediately following testing please fax report to SureHire Inc. at 1.877.500.2620.
Direct testing inquiries to Melanie Ashton at (403)866-4389
Thank You
Billing Information: |
Dr. Marthinus Strydom Prac ID #: 34580-8101 |
 | |||||
| Consent to Disclose Personal Health Information to SureHire | |||||
| Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA) | |||||
| I, ___________________________________, authorize ___________________________________ | |||||
| (Client name) | (Print name of health information custodian) |
| to disclose my personal health information consisting of chest x-ray results |
| to:SureHire Medical Review Team Fax: 1-877-500-2620 |
| for the purpose of: Lung Health Screening |
| Date Consent is Effective: ____________________________________ |
| Expiry Date: ____________________________________ |
| (Valid for 2 years if no date provided) |
| I understand the purpose for disclosing this personal health information to the establishment noted above. I am aware of the risks and benefits of consenting or refusing to consent. I understand that I can refuse to sign this consent form and that I may revoke consent at any time in writing. |
| *Please note that any cost for providing copies of above mentioned reporting is the responsibility of the client, and SureHire is NOT responsible for any applicable fees/payments.* |
| Client name (please print): ____________________________________________________ |
| Client Signature: ____________________________________________________ |
| Personal Health Number: ____________________________________________________ |
| Date: ____________________________________________________ |
