Allison Breast Center
at
Monument Radiology
7301 Forest Ave, Ste 110
Richmond, VA 23226
Phone: (804)288-8321
Fax: (804)285-3245
Patient History
Date: ______
Name: ______Date of Birth: ______
Location of last mammogram: ______
Are you or your doctor feeling a NEW lump or thickening?YESNORight Left
Do you have any BLOODY nipple discharge?YESNORight Left
Do you have any breast PAIN?YESNORight Left
Do you have breast IMPLANTS?YES NORight Left
Have you ever had BREAST cancer?YESNORight Left
SURGERIES / RIGHT / LEFT / DATE OF SURGERY / OUTCOMEBIOPSY
LUMPECTOMY
MASTECTOMY
RADIATION THERAPY
CHEMOTHERAPY
Any chance you are pregnant?YESNO
Do you have a relative with a history of BREAST cancer?YESNO
PRIMARY RELATIVE Age of Onset Secondary Relative Age of Onset
Mother ______Grandmother: ______
Sister ______Aunt: ______
Daughter ______Cousin: ______
Technologist Comment(s):
______
______
Technologist: ______
Allison Breast Center
at
Monument Radiology
7301 Forest Ave, Ste 110
Richmond, VA 23226
Phone: (804)288-8321
Fax: (804)285-3245
I hereby authorize: ______
(Name of physician or hospital)
to release my films and reports to Allison Breast Center at Monument Radiology.
Patient Name: ______
Date of Birth: ______SSN: ______
Patient Signature: ______
Date: ______
Please note that we prefer DICOM CDs.
Thank you in advance.
Allison Breast Center
at
Monument Radiology
7301 Forest Ave, Ste 110
Richmond, VA 23226
Phone: (804)288-8321
Fax: (804)285-3245
Permission to Disclose Private Health Information (PHI)
Patient Name: ______DOB: ______
By signing this paper below, I give permission to the person(s) listed in the table documented to receive Private Health Information or other authorization as listed in the comments section(s). I understand this form is legally binding and that I may revoke my authorization at any time by submitting a request to change, add, or terminate such permission in writing.
Date of Permission / Name of Individual / Comments/Instructions(ex: May pick up medical Records) / Patient Initials / Date Permissions Revoked / Telephone Number
In order to obtain information by telephone, the party calling the practice must be able to share the patient's full name and date of birth with the staff.
Signature of Patient: ______
Relationship (if not self): ______
Allison Breast Center
at
Monument Radiology
7301 Forest Ave, Ste 110
Richmond, VA 23226
Phone: (804)288-8321
Fax: (804)285-3245
ULTRASOUND
Do you need ultrasound?
Some women have an immense amount of dense fibroglandular tissue – the milk glands and supportive tissues in the breast. A mammogram does not penetrate dense tissue very well, resulting in the possibility of abnormalities to be hidden by it. Until the last few years, radiologists had to rely upon the mammogram alone to determine if a woman had breast cancer.
We have learned, over the past few years, that breast ultrasound can detect abnormalities in dense breast tissue that do not show up on the mammogram. Most of the abnormalities turn out to be harmless, like cysts or fibroadenomas, but sometimes a cancer is found, and sometimes that cancer cannot be felt on physical examination or seen on the mammogram. In such cases, ultrasound can be lifesaving.
Not everyone needs breast ultrasound. Mammograms are exceptional at detecting cancers in women whose breasts are predominantly made of fatty tissue. Dr. Bigg will look at the mammogram, and decide whether your breast tissue is dense enough to hide possible cancers, and require an ultrasound examination. Since Dr. Bigg must take responsibility for interpreting your examination, he must make the decision whether or not an ultrasound is needed.
If you do require an ultrasound, it may affect your insurance coverage, so check with your insurance company to estimate your final costs.
You may decline ultrasound examination if you wish, but please understand that your decision deprives Dr. Bigg of a tool he considers important in detecting breast cancer. When ultrasound is indicated, he needs all tools including mammography, ultrasound, and CAD scan to maximize his ability to accurately evaluate a patient.
I have read and understand the above:
Patient Name: ______
Patient Signature: ______Date: ______
Allison Breast Center
at
Monument Radiology
7301 Forest Ave, Ste 110
Richmond, VA 23226
Phone: (804)288-8321
Fax: (804)285-3245
Financial Policy Statement
We will bill your insurance carrier solely as a courtesy to you. If your insurance provider does not pay the entirety of your bill, we will then bill you for the unpaid portion. Typically, however, insurance companies are required to pay for your annual screening mammogram if you are 40 years of age or older. If your insurance company does not remit payment within 60 days, the balance will be due in full from you. In the event that your insurance carrier requests a refund of payments made, you will be responsible for money refunded to your insurance company. In the event your insurance company establishes an internal Usual and Customary Fee Schedule, you will be responsible for the remaining difference. If any payment is made directly to you for services billed by us, your recognized obligation is to send the payment promptly to Monument Radiology.
I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs associated with collecting money owed, including court costs, collection agency fees, and attorney fees.
I, hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, private insurance, and third party payers to Monument Radiology/Allison Breast Center. A photocopy of this assignment is considered as valid as the original.
______
Printed Patient NameDate
______
Patient SignatureDate
______
Allison Breast Center Representative SignatureDate
MONUMENT RADIOLOGY/ALLISON BREAST CENTER
PATIENT INFORMATION FORM (PLEASE PRINT)
WE ARE PLEASED THAT YOU HAVE CHOSEN US TO PROVIDE YOUR MAMMOGRAPHY SERVICES. PLEASE COMPLETE THIS FORM SO THAT WE HAVE ALL THE INFORMATION WE NEED TO SERVE YOU.
CHART # ______
NAME: ______DOB: ______AGE:______
FIRST, MIDDLE INITIAL, LAST
LAST 4 DIGITS OF SSN: ______MARITAL STATUS: M ___ S ___ D ___ W ___
ADDRESS: ______CITY & ZIP: ______
HOME PHONE: ______WORK PHONE: ______CELL PHONE: ______
EMAIL: ______PREFERRED CONTACT: H ___ W ___ C ___ E ___
EMPLOYER: ______OCCUPATION: ______
EMERGENCY CONTACT: ______PHONE: ______
SPOUSE'S NAME: ______DOB: ______
SPOUSE'S EMPLOYER: ______SPOUSE'S OCCUPATION: ______
PRIMARY INSURANCE INFORMATION
NAME OF INSURANCE COMPANY: ______
NAME OF INSURED: ______DOB: ______
POLICY NUMBER: ______GROUP NUMBER: ______
SECONDARY INSURANCE: YES ______NO ______
IF YES, NAME OF COMPANY: ______
NAME OF INSURED: ______DOB: ______
POLICY NUMBER: ______GROUP NUMBER: ______
CONSENT FOR CARE & TREATMENT
I, THE UNDERSIGNED, DO HEREBY AGREE AND GIVE MY CONSENT FOR MONUMENT RADIOLOGY/ALLISON BREAST CENTER TO FURNISH MEDICAL CARE AND TREATMENT CONSIDERED NECESSARY AND PROPER IN DIAGNOSING OR TREATING HIS/HER PHYSICAL CONDITION.
I HAVE READ AND RECEIVED A COPY OF THE PRIVACY POLICY:
PATIENT SIGNATURE: ______DATE: ______
Allison Breast Center
at Monument Radiology, PC
7301 Forest Ave., Ste. 110
Richmond, VA 23226
(804)288-8321
Patient Name: ______Date: ______
Cancellation/Missed Appointment Policy
Your appointment time has been set aside for you, making this time unavailable to other patients. Therefore, we require at least a 12 hour advance notice if you need to cancel your appointment. For all missed or canceled appointments with less than 12 hours notice, you will be charged a $25.00 missed appointment fee. Appointment reminder calls are made both a week before and a day before your appointment to ensure that you are aware of your appointment, and to allow time for you to reschedule, if necessary. If you need to reschedule or cancel your appointment, please do so as soon as possible to avoid the cancellation fee. We cherish you as a patient, and understand that your time is precious, and hope that you understand that ours is too.
I have read and understand the cancellation/missed appointment policy: ______
(Patient Signature)