Patient form

Electronic Pre-Visit Form Submission

Please indicate which center you are scheduled to be scanned:

For Partners Use

Patient Registration Form:

Address

Insurance and co-pays : It is the policy of Partners Imaging Centers to collect any co-pays, deductibles or co-insurance at the time of service. The amount collected is normally regulated by your insurance provider. Payment can be made by cash, debit or credit card. It is possible that your insurance provider may not cover the entire cost of the service provided. In this event, you are responsible for any balance outstanding. A statement will be sent to your home address. Any balances detailed on the statement are due immediately unless a payment arrangement has been made with our billing department

Authorization for access by others to your Protected Health Information ( PHI )

Please check all situations below where you would grant individuals listed below access to your PHI :

Acknowledgment : By submitting this form, I hereby permit Partners Imaging Centers to disclose my PHI to the individual(s) indicated above. I understand each individual that I have listed will be required to provide a valid ID as proof that they are whom they claim to be, in order for my PHI to be released. I also understand that Partners Imaging Centers reserves the right to deny individuals listed access to my PHI records.

For Partners Use

ASSIGNMENT OF BENEFITS / RELEASE OF INFORMATION / FINANCIAL RESPONSIBILITY

I hereby authorize Partners Imaging Center to provide treatment and/or examination, and release any pertinent information to my physicians, insurance company, other third party payors, adjustor or attorney if applicable, and to apply for Medicare/Medicaid, and other health insurance benefits if applicable, (No fault, Personal Injury Protection and Workers Compensation) on my behalf and to take all necessary steps to collect such benefits, including but not limited to filing for arbitration as provided by statutes.

I hereby authorize payment of any/all medical benefits and insurance proceeds be made on my behalf to the above. I certify that the information I have reported the release with regard to my insurance carrier(s) is correct. I authorize the release of medical information about me to my physicians, health insurance carrier and the Center for Medicare and Services (CMS) agents, and any and all other information needed to determine the benefits payable for related service(s).

If medical insurance information is received at the time of service, as a courtesy, all claims will be submitted to your insurance company. Insurance co-payments and annual deductibles not met for the year are payable when services are rendered. Any services that are not fully reimbursed by your insurance carrier and are indicated on your insurances Explanation of Benefits to be the patients responsibility will be due and payable upon receipt of a billing statement. Also please be aware that this imaging center will not forgive patient deductibles, patient co-payments, and patient coinsurance payments.

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES Privacy Practices Document

By signing below, I hereby acknowledge receipt of Partners Imaging Center Notice of Privacy Practices

Please indicate what types of scan(s) you are having:

For Partners Use

MRI Screening Form

( Please check )

Yes No

For SAFETY reasons, please answer the following questions

Pacemaker, heart valve, stent, filter, nitro patch, or other cardiac implants (circle)
Have you ever had brain surgery?
Do you have aneurysm clips in the brain?
Have you ever had surgery on the eyes or inner ears?
Do you have metal in your eyes?
Have you ever worked with cutting, grinding, or welding metal?
Do you have any implanted devices in your body? (pain pump, insulin pump, bone growth stimulator, tens unit, penile implant, etc..) please list
Do you wear hearing aids? (Please remove prior to MRI)
Do you have tattooed eyeliner, body piercing (please circle)
Do you have metal in your body? (shrapnel, gunshot wound, surgically implanted rods, pins, plates, screws, IUB, etc…)
Do you wear removable dental work? (may need to be removed)

( Please check )

Yes No

For CLINICAL reasons, please answer the following questions

Are you possibly pregnant? Or nursing?
Have you ever been diagnosed with cancer?
Do you have anemia, sickle cell anemia, or hemolytic anemia?
Do you have any kidney disease or renal failure?

On certain exams, we may need to inject a special image enhancement agent (Gadolinium) to improve the images that are created on your exam. This agent is safe; however, a small number of patients may experience headaches, nausea or vomiting. Serious reactions occur in less than 1% of patients. A medication guide is available on request. I have read and understand the above. I give consent for this exam and the injection of Gadolinium if necessary. I hereby certify that the above questions have been answered to the best of my knowledge.

TECHNOLOGIST NOTES: (Must note signs/symptoms, history and scan performed)

10cc of PH / MH




For Partners Use

PROSTATE MRI HISTORY FORM

Yes No
Yes No
Yes No
Yes No

If positive biopsy, left or right lobe (if known) Base, Mid-gland or Apex?

( if experimental)

For Partners Use

CT & PET/CT Patient History Questionnaire

Yes No
Yes No
Yes No
AsthmaYes No Hay FeverYes No
Lung DiseaseYes No Heart DiseaseYes No
Thyroid DiseaseYes No Kidney DiseaseYes No
Sickle Cell DiseaseYes No Multiple MyelomaYes No
PheochromocytomaYes No DiabetesYes No
Oral Insulin DietYes No
MedicationYes No
X-Ray Dye (iodine)Yes No
Yes No

For Partners Use

INFORMED CONSENT FOR CONTRAST INJECTION

I hereby authorize the Supervising Radiologist and/or qualified Technologist to administer an injection of contrast medium for the purpose of enhancing body organs and vascular structures for a more complete diagnostic study.

I have been made aware that it is possible to experience an allergic-type reaction to the injection. The most common reactions include nausea, vomiting, flushing or a generalized feeling of warmth. Other reactions include hives, chills, fever, sweating, headache, dizziness, weakness, severe itching, sneezing etc. I understand that an adverse reaction is usually mild and transient, although life threatening reactions have occasionally been reported. For this reason, I understand that well trained personnel are available to treat me in the event of a serious reaction.

Notify the Technologist and/or Radiologist before signing, if you are taking Glucophage for Diabetes, or if you have any of the following conditions : sickle cell disease, multiple myeloma or pheochromocytoms.

I authorize the above to administer any additional medications or treatment deemed necessary to aid in the relief of any reaction.

I have read and understand the above and agree to the injection of contrast medium.