Exhibit 10.12

EXECUTIVE SEVERANCE AGREEMENT
This Executive Severance Agreement (“Agreement”) is made effective as [___],
between Alliance HealthCare Services, Inc., a Delaware corporation (the
“Company”), and [___], an executive of the Company (“Executive”), with reference
to the following facts:
A.     The Company desires the benefits of having Executive serve as an
executive of the Company secure in the knowledge that certain severance benefits
will be paid or provided to Executive in the event of Executive’s termination
from the Company “Without Cause,” or a resignation by the Executive for “Good
Reason,” as such terms are defined below and subject to the terms of this
Agreement.
B.     The parties believe it appropriate to memorialize the Company’s severance
obligations to Executive, as set forth below.
NOW, THEREFORE, in consideration of good and valuable consideration the receipt
of which is hereby acknowledged, the parties hereby agree as follows:
1.     Severance Protection. Effective as of the date of this Agreement and
provided that the Executive satisfies the conditions described in this
Agreement, the Company agrees that should Executive’s employment subsequently be
terminated by the Company “Without Cause” (as defined in Section 4 below) or
resignation by the Executive for “Good Reason” (as defined in Section 5 below),
the Company shall pay Executive severance pay equal to eighteen (18) months of
Executive’s then-current annual base salary (such time period shall be referred
to herein as the “Salary Continuation Period”), payable on a bi-weekly basis. In
such event, the Company shall also pay Executive an amount equal to 100% of
Executive’s then current annual target incentive bonus (“Target Bonus”) for each
year (or portion thereof) of the Salary Continuation Period. Irrespective of any
claim or potential claim Executive may have under any plan document or other
agreement, Executive agrees that he/she expressly waives any and all rights to
any Target Bonus they may have been eligible to receive for the months prior to
the Date of Termination. For example, if the Executive’s Target Bonus for the
year in which the date of Executive’s termination of employment with the Company
(“Date of Termination”) occurred is determined to be equal to $100,000 and the
Salary Continuation Period is eighteen (18) months in length, and the
Executive’s Date of Termination is June 30th, the Company shall pay Executive a
total Target Bonus payment of $150,000. The Target Bonus payment shall be
payable by the Company on a bi-weekly basis during the Salary Continuation
Period. Except as otherwise provided in Section 3(d) below, the payments
provided under this Section 1 shall commence within sixty (60) days of
Executive’s termination of employment.
2.     Other Severance Benefits. Upon termination of Executive’s employment
entitling Executive to severance payments as set forth in Section 1 above, the
Company shall also: (i) pay Executive a bi-weekly amount equal to the Company’s
employer coverage expense for Executive’s (and Executive’s dependents’, where
applicable) group health (medical, dental and vision, where applicable) coverage
as of (“Separation Date”), payable during the Salary Continuation Period for use
by Executive in paying the post-employment premium cost of life, short-term
disability and long-term disability insurance benefits (whether converted to an
individual plan from the Company’s group coverage for such benefits or otherwise
purchased in the private market) or as Executive otherwise deems appropriate, in
Executive’s sole discretion; and (ii) the Company shall reimburse Executive’s
actual costs up to $35,000 for an outplacement firm of the company’s choosing
related to Executive’s search for new employment. Executive must begin
Executive’s participation with such outplacement firm no later than sixty (60)
days following Executive’s Separation Date, to conclude at the

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Exhibit 10.12

end of the Salary Continuation Period or at such time that Executive secures
other employment or self-employment, whichever is earlier. In addition, fees for
outplacement services will be paid directly to the applicable agency by the
Company. All outplacement services and expenses must be reviewed and approved by
the Company prior to payment.
3.     Conditions of Payment. In order to become eligible to receive the
payments and benefits described above and to continue to be eligible to receive
such payments during the Salary Continuation Period, Executive must satisfy the
conditions of this Agreement, including the provisions set forth in this Section
3.
(a)     General. The payment of all severance amounts hereunder shall be less
applicable withholding and shall be treated by the Company and Executive as
severance/liquidated damages to compensate Executive for any and all claims or
damages incurred by Executive of any kind or nature whatsoever, including but
not limited to, contractual, compensatory and punitive damages arising out of or
relating to the termination or end of Executive’s employment with the Company.
In addition, in exchange for and as a further condition precedent to receiving
such potential severance pay/liquidated damages, Executive agrees that within
twenty one (21) days of the termination or end of Executive’s employment with
the Company Without Cause or for Good Reason, Executive must sign (and then not
revoke) a release of any and all claims that Executive has or may have against
the Company and its past and then current officers, directors and employees
relating to or arising out of Executive’s employment (or termination of
employment) with the Company (under this Agreement or otherwise), in a form
prescribed by the Company. Executive further acknowledges and agrees that the
potential severance pay and benefits referenced above shall not be available to
Executive should Executive resign employment with the Company for any reason
other than for Good Reason, or should Executive be terminated by the Company for
Just Cause.
(b)    Non-competition. Executive agrees that no Competition Event (as defined
below) shall occur prior to the date on which Executive ceases to receive
payments and benefits pursuant to this Agreement. For purposes of this
Agreement, a “Competition Event” shall occur if Executive directly or indirectly
(i) engages in any imaging, radiation therapy or any other business that becomes
material to the Company’s business during Executive’s employment by the Company
(the “Company Business”) within the United States that is the same or
substantially similar to or competitive with any service provided by the
Company; (ii) competes or participates as an agent, employee, officer, director,
consultant, advisor, representative or otherwise in any enterprise engaged in a
business which has any operations engaged in the Company Business within the
United States that is the same or substantially similar to or competitive with
any service provided by the Company; or (iii) competes or participates as a
stockholder, partner or joint venturer, or has any direct or indirect financial
interest, in any enterprise which has any material operations engaged in the
Company Business within the United States that is the same or substantially
similar to or competitive with any service provided by the Company. Should a
Competition Event occur before or during the Salary Continuation Period, as
defined in Section 1, above, the Company’s obligations under Sections 1 and 2
shall cease as of the date of the Competition Event. Notwithstanding the
foregoing, Executive shall be required to comply with the requirements of
Section 3, above, as long as the Company has paid Executive the equivalent of
one month’s base salary at the then-current rate as of Executive’s Separation
Date.
(c)     Non-solicitation. Executive agrees that, following the termination of
Executive’s employment relationship with the Company for any reason, Executive
will not (a) disrupt, damage, impair or interfere with the business of the
Company, whether by way of interfering with its employees, disrupting

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Exhibit 10.12

its relationships with customers, consultants, agents, representatives or
vendors or otherwise, through unfair, unlawful or fraudulent means, or (b)
recruit, entice, induce or encourage any of the Company’s employees,
consultants, independent contractors or any third party to engage in any
activity which, were it done by Executive, would violate any provision of this
Agreement. In particular, without limiting the generality of the foregoing,
Executive shall not at any time during the Salary Continuation Period, either
directly or indirectly, as an employee, employer, consultant, partner, officer,
director, shareholder, member, manager, agent or principal or in any other
individual or representative capacity (i) induce or influence any person who is
engaged by the Company as an employee, agent, associate, independent contractor
or in any other capacity to terminate his or her employment or engagement with
the Company; (ii) solicit, induce, attempt to solicit or induce, or cause anyone
to solicit induce, attempt to solicit or induce, for any reason, any customer or
client of the Company to terminate its relationship with it or modify its
relationship with it in a way that would negatively affect the Company,
including, but not limited to, diverting any business or income from it or any
of its affiliates, through unfair, unlawful or fraudulent means.
For purposes of Sections 3(b) and 3(c), the term “Company” shall include
Alliance Imaging, Inc., its subsidiaries and/or its affiliates.
(d)    Section 409A.
(i)    Section 409A Compliance. The parties intend that any amounts payable
hereunder that could constitute “deferred compensation” within the meaning of
Section 409A of the Internal Revenue Code of 1986, as amended (the “Code”), will
be compliant with Section 409A. If the Company shall determine that any
provision of this Agreement does not comply with the requirements of Section
409A, the Company shall amend the Agreement to the extent necessary (including
retroactively) in order to comply with Section 409A (which amendment shall not
reduce the amounts payable to Executive under this Agreement). The Company shall
also have the discretionary authority to take such other actions to correct any
failures to comply in operation with the requirements of Section 409A. Such
authority shall include the power to adjust the timing or other details relating
to the awards and/or payments described in this Agreement (but not the amounts
payable to Executive under this Agreement) if the Company determines that such
adjustments are necessary in order to comply with or become exempt from the
requirements of Section 409A.
(ii)     Separation from Service. Notwithstanding anything in this Agreement to
the contrary, no termination benefits deemed deferred compensation subject to
Section 409A of the Code, shall be payable pursuant to this Agreement unless
Executive’s termination of employment constitutes a “separation from service”
with the Company within the meaning of Section 409A and the Department of
Treasury regulations and other guidance promulgated thereunder (a “Separation
from Service”) and, except as provided under Section 3(d)(ii) of this Agreement,
any such termination benefits shall not be paid, or, in the case of
installments, shall not commence payment, until the sixtieth (60th) day
following Executive’s Separation from Service. Any installment payments that
would have been made to Executive during the sixty (60) day period immediately
following Executive’s Separation from Service but for the preceding sentence
shall be paid to Executive on the sixtieth (60th) day following Executive’s
Separation from Service and the remaining payments shall be made as provided in
this Agreement.
(iii)     Specified Employee. Notwithstanding any provision to the contrary in
this Agreement, if Executive is deemed by the Company at the time of Executive’s
Separation from Service to be a “specified employee” for purposes of Section
409A(a)(2)(B)(i) of the Code, and Executive is not

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Exhibit 10.12

“disabled” within the meaning of Section 409A(a)(2)(C), to the extent delayed
commencement of any portion of the benefits to which Executive is entitled under
this Agreement is required in order to avoid a prohibited distribution under
Section 409A(a)(2)(B)(i) of the Code, such portion of Executive’s benefits shall
not be provided to Executive prior to the earlier of (i) the expiration of the
six-month period measured from the date of the Executive’s Separation from
Service or (ii) the date of Executive’s death. Upon the first business day
following the expiration of the applicable Code Section 409A(a)(2)(B)(i) period,
all payments deferred pursuant to this Section 3 d)(ii) shall be paid in a lump
sum to Executive, and any remaining payments due under this Agreement shall be
paid as otherwise provided herein.
(iv)     Expense Reimbursements. To the extent that any reimbursements payable
pursuant to this Agreement are subject to the provisions of Section 409A of the
Code, any such reimbursements payable to Executive pursuant to this Agreement
shall be paid to Executive no later than December 31 of the year following the
year in which the expense was incurred, the amount of expenses reimbursed in one
year shall not affect the amount eligible for reimbursement in any subsequent
year, and Executive’s right to reimbursement under this Agreement will not be
subject to liquidation or exchange for another benefit.
(v)     Installments. For purposes of Section 409A of the Code (including,
without limitation, for purposes of Treasury Regulation Section
1.409A-2(b)(2)(iii)), Executive’s right to receive the installment payments
under this Agreement shall be treated as a right to receive a series of separate
payments and, accordingly, each such installment payment shall at all times be
considered a separate and distinct payment.
4.     Termination Without Cause; Termination for Just Cause. For purposes of
this Agreement, termination “Without Cause” shall mean any termination of
Executive’s employment by the Company for any reason other than a “Termination
for Just Cause”, which shall include, but not be limited to, the following:
(a)
Executive is convicted of, or pleads guilty or no contest to any crime that
constitutes a felony, or any misdemeanor that involves the purchase or sale of
any security, the taking of a false oath, the making of a false report, bribery,
perjury, burglary, larceny, theft, robbery, extortion, forgery, counterfeiting,
fraudulent concealment, embezzlement, fraudulent conversion, or misappropriation
of funds or securities, or a conspiracy to commit any of these offenses, or
substantially equivalent activity;

(b)
Executive commits any act of theft, dishonesty, fraud or embezzlement;

(c)
Executive fails to perform Executive’s duties to the reasonable satisfaction of
the Company or to carry out instructions by the executive officers or the Board
of Directors of the Company, or breaches Company policies or procedures. Unless
the Company, in its sole discretion, determines that such a failure or breach is
incurable, such failure or breach will only constitute grounds for Termination
for Just Cause if such failure or breach is not cured by Executive to the
satisfaction of the Company within 15 business days after the Company gives
Executive written notice identifying the manner in which the Company believes
that Executive failed to perform or breached;

(d)
Executive, in the reasonable judgment of the Company, causes the reputation and
goodwill of the Company to suffer substantial damage, or subjects the Company to
legal harm; or

(e)
Executive, in the reasonable judgment of the Company, engages in conduct
disloyal to the Company and/or breaches Executive’s fiduciary duties to the
Company.

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Exhibit 10.12

Executive acknowledges that nothing herein is intended to modify, alter,
abridge, or in any way impact the at-will nature of the employment relationship
between Executive and the Company.

5.     Resignation for Good Reason. For purposes of this Agreement, resignation
by Executive for “Good Reason” shall mean resignation only for the following
events that occurs without the Executive’s written consent: (a) the Company
materially reduces Executive’s base salary, (b) the assignment to the Executive
of any duties which diminish in any material respect the Executive’s position
with the Company (including status, offices, titles and reporting requirements),
authority, duties or responsibilities, (c) any material failure by the Company
to comply with any of the provisions of any employment agreement between
Executive and the Company, which is not remedied within 30 days after written
notice thereof from the Executive, (d) if Executive is not based in Alliance’s
Resource Center in Southern California, and the Company requires Executive to
materially change the location of Executive’s principal office to a facility or
a location more than sixty (60) miles from Executive’s then-current residence,
(e) if Executive’s principal office is located in Alliance’s Resource Center in
Southern California, and the Company moves Alliance’s Resource Center more than
sixty (60) miles from the then present office location, (f) Company or any of
its affiliates has completed an acquisition transaction which results in the
legal, beneficial or equitable ownership transfer of at least a majority of the
aggregate of all voting equity interests. The Company and Executive further
agree that for a resignation to constitute a resignation by Executive for “Good
Reason”, Executive must provide written notice to the Company of Executive’s
intent to resign within thirty (30) days of one of the triggering events
outlined in this Section 5.
6.    Excess Parachute Payments.
(a)     Excise Tax. Generally, it is the intention of the Company and Executive
that Executive receives the full benefits available under this Agreement in the
event of a termination Without Cause, or a resignation by Executive for Good
Reason. In the event that:
(i)     all or any portion of any payment or benefit provided by the Company
pursuant to this Agreement (a “Payment”), would be subject to the excise tax
imposed by Section 4999 of the Code (or any successor provision thereto), by
reason of being considered “contingent on a change in ownership or control” of
the Company, within the meaning of Section 280G of the Code (or any successor
provision thereto), or any interest or penalties with respect to such tax (such
tax, together with any such interest and penalties, being hereafter collectively
referred to as the “Excise Tax”), and
(ii)     the aggregate present value of Executive’s “parachute payments” as
defined in Section 280G(b)(2) of the Code and as determined in accordance with
the requirements of Section 280G of the Code and the regulations promulgated
thereunder (“280G Parachute Value”) exceeds 110% of Executive’s “280G Parachute
Limit” (such limit is equal to three times Executive’s “base amount” (as defined
in Section 280G(b)(3) of the Code)), then the Payments shall be reduced such
that the 280G Parachute Value that Executive is entitled to receive shall be one
dollar ($1) less than the maximum amount which Executive may receive without
becoming subject to the tax imposed by Section 4999 of the Code.                
(b)     Determination. The amount of the Excise Tax, or whether a reduction of
Payments is required pursuant to Section 6(a), and the amount of such Payment
reduction, if any, shall be determined by a nationally recognized accounting
firm (the “Accounting Firm”) selected by the Company and reasonably

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Exhibit 10.12

acceptable to the Executive. For purposes of making the calculations required by
this Section, the Accounting Firm may make reasonable assumptions and
approximations concerning applicable taxes and may rely on reasonable, good
faith interpretations concerning the application of Sections 280G and 4999 of
the Code. The Company shall bear all fees and expenses that the Accounting Firm
may reasonably incur in connection with any calculations contemplated by this
Section. The Company and the Executive shall furnish to the Accounting Firm such
information and documents as the Accounting Firm may reasonably request in order
to make its determination under this Section. The Company shall direct the
Accounting Firm to submit its determination and detailed supporting calculations
to both the Company and the Executive within thirty (30) days after the date on
which the release described in Section 3(a) above becomes effective.     
7.     Equitable Remedies. Executive acknowledges that irreparable damage would
occur in the event of Executive’s breach of the provisions of this Agreement. It
is accordingly agreed that, in addition to any other remedy to which it is
entitled at law or in equity, the Company shall be entitled to an injunction or
injunctions to prevent breaches of this Agreement and to enforce specifically
the terms and provisions of this Agreement. Moreover, Executive agrees that, in
addition to any other remedies available to the Company by operation of law or
otherwise, if Executive breaches of any of the obligations contained in Section
3, Executive shall: (i) forfeit at the time of the breach the right to any
additional severance package pay and benefits, and (ii) be required to refund to
the Company the amount of any and all such severance package pay and benefits
already paid to or on behalf of Executive by the Company following the initial
breach, if any, notwithstanding any provisions of this Agreement or such plans
or programs to the contrary.
8.     Successors. This Agreement establishes contract rights which shall be
binding upon, and shall inure to the benefit of, the successors, assigns, heirs
and legal representatives of the parties hereto.
9.     Attorneys’ Fees. The prevailing party in any action to enforce this
Agreement shall be entitled to receive reasonable attorneys’ fees and costs.
10.     Severability. Should any provision of this Agreement or any clause
hereof, be held to be invalid, illegal or unenforceable, in whole or in part,
the remaining provisions and clauses of this Agreement shall remain fully
enforceable and binding on the parties.
    11.     Modification and Waiver. No supplement, modification or amendment of
this Agreement shall be binding unless executed in writing by both of the
parties hereto. No waiver of any of the provisions of this Agreement shall be
deemed or shall constitute a waiver of any other provisions hereof (whether or
not similar) nor shall such waiver constitute a continuing waiver.
12.     Choice of Law and Venue. The validity, interpretation, performance and
enforcement of this Agreement shall be governed by the laws of the State of
California. Any legal proceedings arising under this Agreement shall be
commenced and maintained only in the Superior Court of the State of California
for the County of Orange or the Southern Division of the United States District
Court for the Central District of California.
13.     Entire Agreement. This Agreement constitutes the entire agreement of the
parties hereto with respect to the subject matter hereof and shall supersede all
prior or contemporaneous written or oral agreements concerning such subject
matter. In addition, the terms of this Agreement shall control, supersede and be
in lieu of the terms of the Alliance Severance Benefits Plan for employees
generally, as it may be instituted, modified or terminated from time to time by
the Company.

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Exhibit 10.12

IN WITNESS WHEREOF, the parties have executed this Agreement effective as of the
day and year first written above.
ALLIANCE HEALTHCARE SERVICES INC., a Delaware corporation
By: ____________________________________
Name: Larry C. Buckelew
Its: Chairman and Chief Executive Officer

EXECUTIVE

By: ____________________________________
Name: [____]