Please
initial ne
xt to your applicable examination type
3D
SCREENING
MAMMOGRAPHY
This examination is oft
en considered a “routine” examination and may be applied to routine
or well-woman benefits.
(By opting in, you understand
there may be a bill for the 3D portion of mammogram by the hospital and/or the radiologist.
The final cost of your
mammogram is dependent upon insurance coverage.)
I would like to O
PT-OUT of adding 3D/tomosynthesis to my screening mammogram.
BONE
DENSITOMETRY
Bone Densitometry is a simple scanning test to determine if you have or are at risk for osteoporosis--a disease that
causes bone to become more fragile over time.
If there is a patient responsibility after the claim
has
been
processed
by
your
insurance,
you
will
receive
a
bill from the radiologist and/or the hospital.
DIAGNOSTIC BREAST
IMAGING
Diagnostic breast imaging is performed to evaluate potential breast problems. This is to ensure that our radiologists get a
clear and accurate
picture of your breasts.
These exams are
not considered
“routine”, “well
-
woman”, or a “screening” to
insurance carriers.
If there is a patient responsibility after the claim has been processed by your insurance, you will
receive a
bill from the radiologist and/or the hospital
INSURANCE
BILLING
(For Hospital Centers Only)
If
there
is
a
patient
responsibility
after
the
claim
has
been
processed
by
your
insurance,
you
could
receive
a
bill. For
centers that are a department of the hospital, you may receive a bill
for
the
physician’s services as well as a separate bill
for
the facility portion from the hospital.
Patient or Representative Signature________________________________________Date______________________
Patient Name: _____________________ Date of Birth:_____________
Exam and Billing Notice
Copyright 2020 Solis Mammography. All Rights Reserved.
click to sign
signature
click to edit
Patient
Name:
Date of
Birth:
Date
Signature of Patient
or
Representative
If applicable, full name of patient’s representative and description of his/her authority to act for the patient:
__________________________________________________________________________________
Authorization for Use or Disclosure of Protected Health Information (continued)
I
authorize
the
use
or
disclosure
of
the
PHI
specified
above
for
the
following
purposes
(the
statement
at
the
request
of
the individual
is a sufficient description of the purpose when an individual initiates the authorization and does not, or elects not
to,
provide
a
statement
of
the
purpose):
I understand that I
may
refuse to
sign this Authorization. My refusal will not affect my ability to obtain treatment, orpayment,
or
eligibility for benefits unless: (i)
my
treatment is related to research and then I will not be permitted to have treatment
without
signing
this
Authorization;
or
(ii)
if/when
I
am
receiving
health
care
solely
for
the
purpose
of
creating
PHI for
disclosure
to
a
third
party
on
provision
of
an
authorization
for
the
disclosure
of
the
PHI
to
such
third
party.
I
understand that
I
may
inspect
or
obtain
a
copy
of
the
PHI
of
which
I
am
being
asked
to
allow
the
use
or
disclosure.
I
understand
that
I have
the
right
to
revoke
this
Authorization
at
any
time
by
sending
such
written
notification
to
Solis
Mammography
Privacy Official
via
mail
to:
Solis
Mammography,
Attn:
Privacy
Official,
15601
Dallas
Parkway,
Suite
500,
Addison,
Texas
75001.Such a revocation will not be
effective to the extent that Solis Mammography has relied on it for the previous use or disclosure
of
the
PHI.
If
I
sign
this
Authorization,
I
have
a
right
to
receive
a
signed
copy
of
it.
I
understand
that
information used
or disclosed pursuant to this
Authorization
may
be subject to re-disclosure
by
the recipient and
may
no longer be protected
by
federal
or
state
law.
This Authorization shall be in force and effective for 10 years from the date of my signature or until I revoke or terminate
my authorization in writing, whichever is later, at which time Solis Mammography authorization to use or disclose thePHI
specified expires.
Authorization for Use or Disclosure of Protected Health Information
Protected Health Information (“PHI”) is information about you, including demographic information, that
mayidentify you and that relates to your past, present, or future health and related health care services.
Consistentwith our Notice of Privacy Practices, Solis Mammography is required to obtain your authorization
to permit thefollowing use or disclosure of your PHI for purposes other than treatment, payment and health
care operations.Solis Mammography will not condition its provision of services to you on whether you
provide authorization for
the requested use or disclosure.
(Check those that apply)
I hereby authorize Solis Mammography to use or disclose the following PHI:
All Procedures
or
Specific Procedures:________________________________________________
To the following individuals(include Full Name)
Name: ________________________________ Relationship: _________________
Name: ________________________________ Relationship: _________________
Copyright 2020 Solis Mammography. All Rights Reserved.
click to sign
signature
click to edit
You have health insurance, but Solis Mammography is out of network with your
plan.
You don’t want your claim submitted to insurance due to privacy
reason.
We want you to know what to expect so that you can make an informed decision. In order to
accomplish this, by signing below, you agree to the following:
All fees for the self-pay service must be paid in full at the time of service. Please note, additional procedures
performed after registration may result in additional
fees*.
Self-pay discount cannot be applied if you have in-network participating insurance coverage, or if you are covered
under a Governmental
Payer.
The self-pay amount covers only the services provided by Solis Mammography. You are financially responsible for
all ancillary services, for example laboratory and pathology, and you will receive a separate bill from the laboratory
or pathology for incurred
charges.
A medical claim will not be submitted to your insurance, even in the event of retro-active insurance coverage.
By my signature below, I acknowledge that I have read and understand the above and have been
given the opportunity to ask questions. I confirm that I am the patient, or the patient’s duly
authorized representative.
Patient or Representative Signature ____________________Date _____________Time _______________
If signed by someone other than the patient, please specify relationship to the patient:
For Office Use Only
Exam
Performed:
Date of Service:
*Self-pay
estimate
paid at time of
service:
Patient Name:_______________Date of Birth:
______________
Self Pay Waiver
Applicable for Self Pay Patients Only-Please skip to next page if not applicable
You are being provided this letter of acknowledgement because you have requested that your
radiology exam today be coded as “self-pay.”
You have requested that this service be coded as self-pay
because
(initial one):
You have no active health
insurance.
Copyright 2020 Solis Mammography. All Rights Reserved.
click to sign
signature
click to edit
Patient Name: ________________________
Date of Birth: ________________
MSP Questionnaire
For Medicare Covered Patients Only-skip to next page if not applicable
Box:
1
Is the patient currently covered under a health plan with their current or previous employer
or
a family member’s health plan?
Yes or No
(Please Circle or Choose One)
If yes,
answer questions in Box 2.
Is the patient’s treatment a result of any injury or are they taking Legal action in conjunction
with the service to be performed?
Yes or
No
(Please Circle or Choose One)
If yes, answer questions in Box 2
Does the patient have End Stage Renal Disease?
Yes or No
(Please Circle or Choose One)
Does the patient have Black Lung Benefits, and if so, is the service to be performed related to
Black Lung?
Yes or No
(Please Circle or Choose One)
Box: 2
Does the employer have more than 20 employees or multi-employer group with more than 20
employees? Or
Is the patient disabled and covered under their current employer or family
member’s employer’s Large Group
Health
Plan with more than 100 employees or a
multi-
employer group with more than 100 employees?
Yes or No
(Please Circle or Choose One)
Is the injury or illness job-related, auto accident related, or related to any type of liability?
Yes or No
(Please Circle or Choose One)
If yes which of the following?
The injury is job related.
The injury is auto accident related.
The injury is liability related.
Copyright 2020 Solis Mammography. All Rights Reserved.
_
_
_
_
_
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and
presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative
order, or in response to a subpoena.
Disclosure to family members, relatives, or personal representatives
Unless you request limitations, as described in “Your Choices”, above, we may
disclose your health information to a family member, other relative, close
personal friend, or any other individual identified by you. We will limit such
disclosures to information directly related to that person’s involvement in your
health care or payment related to your health care.
Unless you request limitations, as described in “Your Choices”, above, we may
use or disclose your health information to notify or assist in notifying a family
member, personal representative, or another person responsible for your care,
location, or general condition.
Disclosure to business associate
We may share your health information with third party “business associates” that
perform certain services (e.g., billing and collections) on our behalf. To protect your
health information, however, we require the business associate to agree in writing
to appropriately safeguard your information.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected
health information.
We will let you know promptly if a breach occurs that may have compromised
the privacy or security of your protected health information.
We must follow the duties and privacy practices described in this Notice and
give you a copy of it.
We will not use or share your health information other than as described in this
Notice unless you tell us we can in writing. If you tell us we can, you may change
your mind at any time. Let us know in writing if you change your mind and we
will then discontinue such use or disclosure.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
.
Changes to the Terms of this Notice
We can change the terms of this Notice, and the changes will apply to all
information we have about you. The new Notice will be available upon request,
in our office, and on our website (www.solismammo.com
). You may also
obtain a copy of our most current Notice at your next appointment or you may
ask our Privacy Official to send a printed copy to you.
This Notice is effective on September 23, 2013.
Rev. 4.2019
NOTICE OF PRIVACY PRACTICES
OF
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have questions about this Notice, please contact our Privacy Official, Leigh
Massey, at 469-398-4134 or leigh.massey@solismammo.com.
Your Rights
When it comes to your health information, you have certain rights. This section
explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record
and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within
30 days of your request. We may charge a reasonable, cost-based fee for any
requested copies.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is
incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we will tell you why in writing within 60
days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment,
payment, or our operations. We are not required to agree to your request, and
we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us
not to share that information for the purpose of payment or our operations with
your health insurer. We will say “yes” unless a law requires us to share that
information.
Get a list of those with whom we have shared information
You can ask for a list (accounting) of the times we have shared your health
information for six years prior to the date you ask, with whom we shared it, and
why.
We will include all the disclosures except for those about treatment, payment,
and health care operations, and certain other disclosures (such as any you
asked us to make). We will provide one accounting a year for free but will
charge a reasonable, cost-based fee if you ask for another one within 12
months.
Get a copy of this Notice
You can ask for a paper copy of this Notice at any time, even if you have agreed to
receive the Notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your
legal guardian, that person can exercise your rights and make choices about
your health information.
We will make sure that person has this authority and can act for you before we
take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting our
Privacy Official using the information on page 1 of this Notice.
You can file a complaint with the U.S. Department of Health and Human
Services Office for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints
.
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we
share. If you have a clear preference for how we share your information in the
situations described below, talk to us. Tell us what you want us to do, and we
will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your
care
Share information in a disaster relief situation
If you are not present, or if the opportunity to agree or object to such disclosure
cannot practically be provided by you because you are incapacitated or there
is an emergency, we may go ahead and share your information if we believe it
is in your best interest. We may also share your information when needed to
lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written
permission:
Marketing purposes
Sale of your information
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with health care professionals
who are treating you.
For example, we will send your radiology report to your treating physician.
Run our organization
We can use and share your health information to run our organization, improve
your care, and contact you when necessary.
For example, members of our quality improvement team may use information
in your health record to assess the services you received from us. This
information will then be used in an effort to continually improve the quality and
effectiveness of the services we provide.
Bill for your services
We can use and share your health information to bill and get payment from
health plans or other entities.
For example, we give information about you to your health insurance plan so it
will pay for the services you receive from us.
How else can we use or share your health information?
We are allowed or required to share your information in other waysusually in ways
that contribute to the public good, such as public health and research. We have to
meet many legal conditions before we can share your information for these
purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
.
Help with public health and safety issues
We can share your health information for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if applicable state or federal laws require it,
including with the U.S. Department of Health and Human Services if it wants to see
that we are complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral
director when an individual dies.
Address workers’ compensation, law enforcement, and other government
requests
We can use or share health information about you:
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