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Lenox Hill Hospital.
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Insurance and Important Forms
In order to save time, the following forms can be printed, and filled out prior to your arrival in the Radiology Department. These forms enable us to properly perform your study, while also providing us with all of the information needed to process your claim.
The links below go to PDF documents. If needed, download Adobe® Acrobat® Reader.
Department of Radiology Form- Authorization
- Questionnaire
- Patient Information Sheet
- IV Consent
- Orthopaedic MRI Questionnaire
- CT Scan Questionnaire
- HIPAA Consent
Insurance Information
Company | HMO | PPO | Medicare | Medicaid |
1199 Benefit Plan | X | |||
Aetna U.S. Healthcare | X | X | X | |
Affinity (formerly Bronx Health Plan) | X | |||
America’s Health Plan (UP & UP) | X | |||
AmeriChoice | X | |||
Anthem | X | |||
Beech Street | X | |||
CenterCare | X | |||
CIGNA HealthCare | X | X | X | |
Community Care Network (CCN) | X | |||
Community Care Partners | X | |||
Consumer Health Network (CHN) | X | |||
Elderplan | X | |||
Empire Blue Cross Blue Shield | X | X | X | |
Fidelis | X | |||
FirstHealth | X | |||
Galaxy (MCI) | X | |||
GHI | X | |||
Health Net (formerly PHS) | X | X | ||
HealthPlus | X | |||
HIP | X | X | X | X |
Horizon | X | X | ||
MagnaCare/MagnaHealth | X | X | ||
Managed Health Inc. (MHI) | X | X | ||
MDNY (cardiac only) | X | |||
MultiPlan | X | |||
Neighborhood Health Providers | X | |||
Oxford Health Plans | X | X | ||
Private Healthcare Systems (PHCS) | X | |||
QHM | X | |||
United HealthCare | X | X | X | X |
USA – MCO | X | |||
Vytra Healthcare | X | X | X |
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