SummerlinImagingCenter
PLEASE FILL OUT FORM COMPLETELY
Name: ______SSN: ______-_____-______
Last First Middle Int.
Home Address: ______City/State/Zip ______
Northern Address: ______City/State/Zip ______
Mailing Address: ______City/State/Zip ______
Home Phone: (___) ______Cell Phone: (___) ______
Date of Birth ___/___/_____ Age: ______Marital Status: S M D W Sex: M F
Circle one Circle one
Do you reside in a Skilled Nursing or aHospice Facility? Yes or No
Name of Facility: ______Phone: ______
***If this is due to an auto accident, where you treated at the Emergencyroom on the day of
the accident? Yes or No
***Attorney’s Name:______Attny’s Phone # ______
Employment Information:
Employer: ______Occupation: ______
Address: ______City/State/Zip ______
Phone:(_____)______Full Time Student: Yes or No
Circle one
Spouse or Guardian Information:
Name:______SSN:______-_____-______
Employer: ______Work # (___) ______
Employer Address: ______
Primary Insurance Subscriber’s Information: (Only if you are NOT the primary on Ins. Card)
Name: ______Relationship: ______
SSN: _____-____-______Date of Birth: ___/____/____ Phone: (___) ______
Emergency Contact: (optional)
Name: ______Phone: (___) ______Relationship______
Assignment of Benefits and Authorization for Treatment
Acknowledgement of Receipt of Notice of Privacy Practices: I hereby certify that I have received a copy of the Notice of Privacy Practices for SummerlinImagingCenter. I also acknowledge that SummerlinImagingCenter reserves the right to revise the notice and that any future changes or revisions will apply to all protected health information contained in my medical records for SummerlinImagingCenter. ***Initial: ______
Consent for Medical Treatment: I authorize Summerlin Imaging Center to furnish the necessary medical treatments, or procedures, including diagnostic x-ray, laboratory procedures, contrast injection, and/or drugs. I also authorize the attending physician(s), his assistants, or his designees to order supplies as needed. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of treatment/diagnostic procedures in Summerlin Imaging Center. I recognize that the physician(s) who practice at SummerlinImagingCenter are not employees of SummerlinImagingCenter, but are independent physicians. Summerlin Imaging Center may delegate to these independent physicians those services physicians normally provide; any questions relating to care which physician has given or ordered should be directed to him/her.
***Initial: ______
Authorization for Release of Information and Medical Records: I hereby authorize SummerlinImagingCenter to release any information regarding diagnosis and treatment requested by referring physician(s) or attorney (if applicable). I also authorize release of same to insurance company to collect benefits under the policies. I further authorize any physician or institution that attended to this patient previously to furnish medical records and/or information which may be requested by SummerlinImagingCenter or attending physician.
***Initial: ______
Please specify names of any persons or parties you would like your medical information withheld from:
______
Assignment of Benefits: I assign my rights to Summerlin Imaging Center of any and all medical benefits applicable and otherwise payable to me. I understand that I am financially responsible to SummerlinImagingCenter for charges not covered by this assignment. I also understand that SummerlinImagingCenter is filing my claims as a courtesy to me and that, unless otherwise stipulated in a contract with my carrier, I am responsible for payment of this claim.
Under newly created Federal Trade Commission Rules, providers of Medical Care are now considered “lenders”
and as “such” must inform me of the following should “collections” (and the additional cost) become necessary: “ Should my balance(s) not be paid in full, I agree to pay the providers cost of collection fees and I agree to pay the
providers cost of attorney fees as may be necessary to effect collection of this note.
***Initial: ______
Liability/Insurance Waiver: I hereby state that I wish SummerlinImagingCenter to submit my claim for services rendered to my insurance company for services rendered for the accident date of ______. I am not filing this claim with any other liability insurance and will not be making any payment to any other general liability insurance that will have to be refunded immediately. I understand that the total amount originally charged for the services rendered will become due and payable by me. Filing your liability insurance does not constitute an assignment. If this is a legal case, we do not accept assignment pending the outcome of your case. You are responsible for your bill in its entirety. ***Initial: ______
Worker’s Compensation: This authorizes my physician to furnish written reports and communicate orally with any representative, attorney for, or investigation from, my worker’s compensation carrier regarding my examination, diagnosis, treatment and prognosis concerning injuries sustained as a result of an accident occurring on ______
***Initial: ______
THIS AUTHORIZATION MUST BE SIGNED IN ORDER TO EXPEDITE THE FILING OF YOUR INSURANCE CLAIM.
______Patient unable to sign due to ______
Print Patient Name
______
PatientSignature (Parent/Guardian if patient is a minor) Date Employee Initials
*** Is there any chance you might be pregnant? Yes or No
Patient Disclosure and Information Consent for MRI
Patient Name ______Date ______MR # ______
Your doctor has requested that you have a Magnetic Resonance Imaging (MRI) exam to aid in your medical diagnosis. It is anticipated that you will benefit from this procedure, as this diagnostic device may offer diagnostic information not available from other techniques.
CONTRAINDICATIONS:
Since MRI uses an electromagnetic field, you cannot undergo this procedure if you have any of the following:Cardiac pacemaker, cochlear implant, neurostimulators, metal fragments in the eye, implanted drug Infusion pump, or prosthetic appliances?
**Please inform us if you have any other implants not mentioned**
Please read and circle YES or NO to the following questions:Weight: ______
Do you have aneursym clips, stents, Do you have a war injury or gunshot wound? Yes No
or filters in your blood vessels? Yes No Are you pregnant ? Yes No
Are you wearing a wig or hairpiece? Yes No When was your last menstrual cycle? ______
Do you have any implanted devices such as electrodes, Are you wearing an IUD? Yes No
neurostimulators, heart valves, orthopedic implants, Do you have any concealed body piercing? Yes No
shunts? Yes No Have you ever had radiation therapy? Yes No
Do you have a history of: Have you ever had a contrast injection? Yes No
Heart disease? Yes No If yes, did you have any adverse effect? Yes No
Kidney disease? Yes No Do you have a history of seizures? Yes No
Cancer? Yes No Have you had any surgery regarding the area we are scanning?
If yes, please describe______If yes when? Yes No
______ ______
Diabetes ? Yes No
High blood pressure? Yes No ______
Allergies? Yes No
Are you claustrophobic? Yes No
Have you ever had a previous MRI or CT of the same area we are scanning today? Yes No
If yes, where and when? LMR Imaging Radiology Regional Lee MemorialHospital Cape CoralHospital
□Riverwalk HealthPark SWFL RegionalHospital Florida Radiology Consultant Other______
PREGNANCY:
The FDA has not established any criteria under which a pregnant woman may be scanned. Therefore, it is the policy of this facility that MR Imaging not be routinely performed on women with known or suspected pregnancy.
CONTRAST:
Your Doctor may request that your exam be performed with intravenous contrast medium (Magnevist) during the MRI exam. Magnevist injection is FDA approved and indicated for use with MRI examinations. Although Magnevist is very safe and allergic reactions are extremely rare, the possibility of an allergic reaction does exist. In addition, related complications such as pain or swelling at the site of injection, or phlebitis, although rare, are possible. The purpose, benefits, and complications of the contrast procedure will be explained to your satisfaction before any injection takes place.
I confirm that the information I provided is complete and accurate to the best of my knowledge. I have read, understand, and hereby consent to this MRI examination.
______
Patient SignatureDate
Parent or Guardian if Patient is a Minor
______Witness Signature Date