Patient Name Social Security #
Sex DOB Age Weight Height
Patient Address
City State Zip
Main Phone Alternate Phone
Email address
Emergency Contact Phone Relationship
Referring Physician
Follow up appointment scheduled: Yes/No Date Time
Health Insurance Company
Person Insured Relationship
Insured’s Birthdate Insured Social Security #
Policy # Group #
Employer Employer Phone
Employer Address
X (please initial) I authorize this facility to release any information or images which were acquired in the
course of my examination or treatment. Written reports generated from your visit will be provided to your
referring physician.
X (please initial) I understand that this oce bills insurance as a courtesy and that payment of these
services are my responsibility. I permit the insurance company to make payment directly to facilities for services
rendered. Also to appeal any claims to my insurance on my behalf. This does not apply to TWCC guidelines.
Patient Signature Date
GENERAL INFORMATION
1.
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Please read and answer each question carefully, as it pertains to you and the test you are having today.
Please describe your medical reason and symptoms for having this examination.
Date of injury Length of symptoms
Have you had a previous MRI, CT, or X-rays related to this problem?
If so where and when?
MRI patients only
Cardiac pacemaker?
Heart disease or arrhythmias?
Other heart surgery, stents or valve?
Neuro-stimulator (Tens Unit) other implanted
electrodes, pumps, or devices?
Brain surgery or aneurysm clip? Other vascular surgery ?
War injury or gunshot wound?
Metal fragments in eye or other body parts
that had to be removed?
Eye surgery or prosthetic (i.e. buckle, cataract, implants)?
Joint and limb replacement metal rod, pin,
screw or other orthopedic device?
Middle ear or orbital prosthesis?
Hearing aid or dentures?
Currently wearing medication/nicotine patch?
Any renal/kidney failure or disease?
Asthma or other lung disease?
High blood pressure?
Have you ever had cancer or radiation therapy?
If so, when?
Tattoos, body piercing or permanent make up?
List previous surgeries
Have you had an allergic reaction to contrast injected for MRI or CAT scan?
Patient Signature Date
Yes No
PATIENT HISTORY & SCREENING FORM
2.
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As the patient you have the right to be informed about your condition and the recommended surgical, medical or
diagnostic procedure your physician has ordered. It is your decision whether or not to undergo the procedure after
knowing the risks and hazards involved. This disclosure is not meant to scare or alarm, it is to educate you so you can make
a decision to continue with your procedure.
Your physician has requested that we perform a study that requires the use of a contrast agent to better visualize the
anatomy. If you have previously had a reaction to a contrast injection, such as hives, severe itching, shortness of breath and/
or significant reaction requiring hospitalization, a history of allergic conditions and/or asthma, any history of anemia, sickle
cell anemia, kidney disorder, or are pregnant or breast feeding you MUST inform the technologist.
The following complications are possible any time an injection is given: Pain, bleeding, swelling or bruising at the injection
site. Exams requiring contrast may result in a mild headache, nausea, itching or other vague symptoms for a short time
after the injection. Other reactions may include hives, shortness of breath or difficult in swallowing. There have been rare
instances of death after the administration of the contrast agent. It is VERY important that you inform the technologist if
you experience any of the conditions mentioned in this form.
Contrast History – Any personal history of:
Immuno Compromised Disease
(AIDS, HIV, HEP-C, etc.)
Do you have diabetes?
-If yes, are you on Metformin or Glucophage?
Seizures/Headaches/Dizziness/Stroke
Allergic Respiratory Disease/Asthma
Kidney/Bladder Disease
Liver Disorder
High Blood Pressure
Are you breastfeeding?
Please list all allergies:
I have answered these questions to the best of my knowledge and understand the information presented to me:
Patient Signature Date
Prime Diagnostic Witness Date
INFORMED CONSENT FOR CONTRAST
(MRI/CT/NUCLEAR MEDICINE ONLY)
Yes No
3.
This form is for female patients only. Male patients may skip this page.
Patient Name:
Age: Are you pregnant: Yes No Maybe
Are you pre or post menopause? Pre Post (If post menopause, you may skip the rest of this form.)
Have you had a hysterectomy or tubal ligation? If so, date of procedure:
If no, are you or your partner using any of the birth control methods listed below? Yes No
Please check the method(s) used:
Birth control pills IUD
Husband vasectomy Sponge
Abstinence/Inactive
Other, please specify
How long have you used this method? Months/Years
First day of your last menstrual period / /
Mo Day Year
Are you breastfeeding? Yes No
I have read and understand the above information and give my authorization for all procedures ordered.
Patient Signature Date
Prime Diagnostic Witness Date
PREGNANCY STATUS INFORMATION
4.
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Is your injury or condition the result of an accident? If yes, please thoroughly complete this page. If not, please move on
to next page.
TYPE OF ACCIDENT
Check all that apply:
Motor Vehicle Accident 18-wheeler Accident Slip and Fall Pedestrian
On the Job DWI Other
ATTORNEY INFORMATION
Name of Attorney: Attorneys Phone #:
Date of Injury:
PATIENT’S MOTOR VEHICLE INSURANCE
Carriers Name: Policy Number:
Name of Insured:
Coverage: PIP: UM/UIM: MEDPAY:
DEFENDANT’S MOTOR VEHICLE INSURANCE
Carriers Name:
Name of Insured:
Policy Number: Claim Number:
ACCIDENT INFORMATION:
Did the Defendant receive a ticket? Yes No Police Report filed? Yes No
City where the accident happened:
How did the accident happen:
Property Damage: $0-$500 $500-$1000 $1000-$5000 $5000 or more Totaled
LETTER OF PROTECTION/WORK COMP
5.
This agreement is entered into this date by and between hereinafter “Patient” and Prime
Diagnostic Imaging, JTP Diagnostics, Foundation Physicians Group, Cellular Medicine Solutions, hereinafter “Provider”. Whereas Patient
desires to receive healthcare services from Provider and desires to assign certain rights and benefits to Provider as an inducement to
cause Provider to wait for payment of such benefits, it is hereby agreed:
SECTION 1. Patient assigns to Provider any and all benefits payable by Patient’s insurance or healthcare plan(s) as a result of charges
incurred by Patient for services rendered by Provider. Patient also assigns to Provider any and all contractual rights Patient has against
any insurance company, healthcare benefit plan or any other party contractually liable to Patient for payment of healthcare costs
incurred by Patient as a result of services rendered by Provider. This assignment of benefits and contractual rights to those benefits shall
not exceed the total amount of charges incurred by patient for services rendered by Provider. Patient agrees that payment for services
rendered by Provider is due upon receipt of said services and Provider’s acceptance of patient assignment of benefits is a convenience
to Patient and that Provider may revoke this assignment at any time.
SECTION 2. Patient thereby directs all insurers and other persons responsible for Patient’s healthcare costs to make all payment for the
healthcare services rendered by Provider directly to Provider.
SECTION 3. Patient agrees to waive any applicable statute of limitations which may at any time interfere with Provider’s right to collect
for services rendered to Patient.
SECTION 4. Patient agrees that in the event Patient receives any check, draft or other payment subject to this Agreement, patient will
act as a fiduciary agent for Provider and will immediately deliver said check, draft or payment to Provider. Provider agrees to apply the
proceeds from the check, draft or payment to Patient’s debt for services rendered.
SECTION 5. A copy of this document shall be as binding as the document bearing original signatures. At the time each claim is
submitted, a copy of the claim will be stored for safekeeping in Patient’s file and may be picked up by the Patient/insured at any time or
will, upon request by the Patient/insured or be mailed to a designated address.
SECTION 6. Patient agrees to be responsible for any deductibles or co-payments required by the terms of any applicable insurance or
healthcare plan. Patient further agrees to pay for any services not covered by Patients insurance or healthcare plan. A refund, if any, will
be calculated upon receipt of payment from your insurance company.
SECTION 7. In the event that any Section or provision of this Agreement is legally void, invalid or unenforceable, all other sections and
provisions of this Agreement shall remain in full force and effect.
SECTION 8. Provider participates/contracts with many, but not all insurance companies. Provider can be determined dependent on the
type of service provided. Contracts are not all the same and certain services may not be covered depending on your benefits. Whether
provider participates with an insurance company or not, you must pay your co-payment, coinsurance and/or remaining deductible at
the time of service. Imaging services may be billed globally or split, technical and professional. You may receive one or two bills. Pain
procedures may be billed by up to three providers, physician, facility, and anesthesiology.
IN WITNESS THEREOF, this agreement has been explained to the (patient’s) satisfaction and having due knowledge and understanding
entered into the day and year set forth below.
Patient Signature Date
Guardian (If patient is a minor) Date
Prime Diagnostic Witness Date
BENEFIT ASSIGNMENT RECORD
RELEASE PAYMENT AGREEMENT
6.
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I have received the Notice of Privacy Practices of Prime Imaging Partners, which explains how my medical information
will be used and disclosed. I understand that I am entitled to receive a copy of this document for my records.
Signature of Patient Or Personal Representative Date
Printed Name of Above Signature
Relation to Patient if Signed by Representative
Prime Diagnostic Witness
ACKNOWLEDGEMENT OF RECEIPT
OF NOTICE OF PRIVACY PRACTICES
7.
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signature
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Patient Name: DOB:
Release to:
Name and address of recipient to whom information is to be released if other than PDI:
Any Requesting Physician Insurance Co. Attorney Hospital Other (Specify):
GENERAL AUTHORIZATION: I authorize the above named healthcare provider to release the information specified below to
the organization or individual named on this request. I understand that my physician(s) may be notified about this request.
I agree to pay the facilitys reasonable charge for copying any documents, and I understand that the facility may require a
reasonable time to make any copies.
INFORMATION REQUESTED:
Radiology Reports
Radiology Images
Clinical Reports
CONDITIONS AND DATES OF CARE COVERED:
All exams at this facility provided as of the date of my signature.
Limited to exam dates and/or conditions described below:
PURPOSE(S) OR NEEDS FOR WHICH INFORMATION IS TO BE USED:
Continuing Medical Care Insurance Request Other (Specify):
EXPIRATION OR REVOCATION OF AUTHORIZATION: I understand that I may revoke this authorization in writing at
any time. I understand that this authorization will not apply to admission or care provided after the date of my
signature. Even if I do not revoke this authorization in writing, this authorization will automatically expire in one
year, or:
On the following date:
Patient Signature Date
AUTHORIZATION TO RELEASE
MEDICAL INFORMATION
8.
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signature
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signature
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