Download Fallbrook Open MRI Patient Data Sheet

Facility:
MRN:
DOS:
Referring:
Radiologist:
Delivery:
Patient Data Sheet
MUST BE FILLED OUT COMPLETELY FOR INSURANCE TO BE FILED
Patient Name _________________________________________________________________ Sex (check one):
Male
Female
Birth Date______________________________ SSN__________________________________ Marital Status ____________________
Home Phone ___________________________ Work Phone _________________________Cell Phone___________________________
Patient Address __________________________________________________________________________ Apt.# _________________
City_____________________________________________ State___________________________ Zip___________________________
Parent/Guardian (if Minor) ___________________________ Parent/Guardian DOB __________________Phone# _________________
Address ____________________________________ City _________________________ State _________________Zip ____________
Insurance Type (check one):
HMO
PPO
POS
W/C
M/C
Indemnity
Other:___________________________
Referring Doctor Name _________________________________________________ Phone ____________________________________
PRIMARY Insurance Co Name__________________________________________________ Phone ____________________________
Policyholder____________________________________ DOB_______________ SSN________________________ Sex ___________
Policyholder’s Employer _________________________________________________________ Phone_________________________
Employer’s Address ____________________________________________________________________________________________
City _______________________________________ State ________________________________ Zip___________________________
Insurance ID # ____________________________________________ Group # _____________________________________________
Patient’s Relation to Insured (check one):
Self
Spouse
Child
Emp
Student
Other:_______________________
SECONDARY Insurance Co Name _______________________________________________ Phone ___________________________
Policyholder____________________________________ DOB________________ SSN________________________ Sex __________
Policyholder’s Emp_____________________________________________ Phone____________________________
Employer’s Address_______________________________________ City __________________ ST ___________ Zip _____________
Insurance ID _______________________________________________ Group # ____________________________________________
Patient’s Relation to Insured (check one): Self
Spouse
Child
Emp
Student
Other: _____________________
If Medicare is Secondary, (check one):
Working Aged Benefiary
Spouse with Employer Group Plan
End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer’s group health plan
No-fault Insurance including Auto is Primary
Public Health Service (PHS) or Other Federal Agency
Disabled Under Age 65 with Large Grp Hlth Plan (LGHP)
Veteran’s Admin
Black Lung
Worker’s Compensation
Other Liability Ins is Primary
WORK COMP or OTHER ACCIDENT RELATED (If an accident, you must fill out this section)
Is condition related to an accident?
Yes
No If Yes (check one): Auto Work Other Accident date: ______________ Claim # ___________________
Where accident occurred, address: ___________________________________ How accident occurred: ___________________________
If Work related: Employer Name, Address & Phone # __________________________________________________________________
Adjuster Name ______________________________________________ Adjuster’s Phone #___________________________________
_
Is this accident covered under any insurance?
Yes
No
If yes, supply the name & address of other carrier:___________________
Emergency Contact: ____________________________________ Phone#: ____________________ Phone#: _____________________
Medical, Film, and/or Billing Release Authorization: I authorize the following person(s) to obtain medical, film and/or billing records:
Print – Name
Relationship to Patient
Phone Number
NOTE: Once your insurance company finalizes the processing of our claim you may receive a bill from Houston MRI & Diagnostic Imaging and IRIS Radiology for fees associated with
the exam(s) performed; however, we will gladly file your insurance claim for you. Verification of benefits is not a guarantee of payment only an estimate of benefits. I understand and
agree that I am primarily responsible for all charges on my accounts not covered by insurance and for all costs of collection, including reasonable attorney's fees. I authorize
treatment and release of medical records to physicians and/or insurance carriers. Additionally, I hereby freely and voluntarily authorize the facility to release and/or obtain my billing
and/or medical records should the request arise by our radiologist, another organization, or myself. I authorize direct payment of all requested payable benefits from insurance and/or
settlements to the provider. Houston MRI & Diagnostic Imaging, IRIS Radiology and CSII will use available written, verbal or electronic means to communicate with Houston MRI &
Diagnostic Imaging and IRIS Radiology patients. This can include email, text messages and telephone calls to your home, wireless or employment telephone numbers When you
provide Houston MRI & Diagnostic Imaging and IRIS Radiology with your contact information, you are expressly consenting to being contacted via any or all of the above mentioned
methods by a live person or automated service/device. You may incur fees for calls and messages from your telecommunications provider for these communications. In addition, if a
payment is not made by the due date and acceptable payment arrangements are not made, Houston MRI & Diagnostic Imaging and IRIS Radiology may use debt collection agencies
or other remedies allowed by law. By providing your telephone numbers to CSII, including wireless and employment numbers, you are expressly consenting to being contacted on those
numbers for any purpose related to your account, including debt collection, by a live person or automated dialing device.
X______________________________________________________________________
Patient or Legal Guardian Signature
_______________________________
Date
Facility:
MRN:
DOS:
Referring:
Radiologist:
Delivery:
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
For office use only:
Patient Name:
Medical Record #:
Date of Service:
By signing this form, you acknowledge that Houston MRI & Diagnostic Imaging has given you a copy of its
Privacy Notice, which explains how your health information will be handled in various situations. We must ask
you to sign this form on your first date of service with us after April 14, 2003.
If your first date of service with us was due to an emergency, we must give you this notice and get your signature
acknowledging receipt of this notice as soon as we can after the emergency.
Check all that are true:
I have received the Houston MRI & Diagnostic Imaging Privacy Notice.
Houston MRI & Diagnostic Imaging has given me the chance to discuss my concerns and questions about
the privacy of my health information.
______________________________________
Patient’s Signature
__________________________
Date
Houston MRI & Diagnostic Imaging staff must complete if Acknowledgement Form is not signed:
Does patient have a copy of the Privacy Notice? Yes No
Please explain why the patient was unable to sign an acknowledgement form and Houston MRI & Diagnostic
Imaging’s efforts in trying to obtain the patient’s signature:
Facility:
MRN:
DOS:
Referring:
Radiologist:
Delivery:
MRI PATIENT HISTORY FORM
Patient Name: ____________________________________________________________ Date: ___________________
Date of Birth: __________________________
Height: _________________
Weight: ____________________
Type of Exam: ______________________________________________________________________________________
When is your next follow-up appointment with your doctor? ________________________________________________
Describe your symptoms for today’s visit: ________________________________________________________________
__________________________________________________________________________________________________
Were you injured?
Yes No
If yes, when? ______________ How (enter details)? _________________________
__________________________________________________________________________________________________
Have you had any surgery relating to this area? Yes
Have you had other surgeries? Yes
No
No
If yes, when? ____________________________________
If yes, what type and when? _____________________________________
__________________________________________________________________________________________________
Have you had any previous imaging studies related to today’s procedure? Yes No
If yes, please list type of study, date, and location: _________________________________________________________
Are you currently taking or have you recently taken any medications? Yes
No
If yes, please list: ____________________________________________________________________________________
Do you have any allergies?
Yes No
Are you allergic to contrast used for MRI’s?
Yes No
If yes, please list: ____________________________________________________________________________________
Do you have or have you had any of the following:
AIDS or HIV
Anemia
Asthma
Cardiac problems
Grand Mal Seizures
Cancer
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Diabetes
Yes No Liver Disease
Dialysis
Yes No Mononucleosis
Hepatitis
Yes No Sickle Cell Anemia
Hypoglycemia
Yes No Stroke
Kidney Disease
Yes No Ulcers
Type: __________________________________
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Please list any other medical conditions not listed above:
__________________________________________________________________________________________________
FEMALE PATIENTS ONLY
I am pregnant (or may be)
I use an IUD
I am breastfeeding
Yes No
Yes No
Yes No
Onset of last menstrual period _____/______/_____
I have had a hysterectomy
Yes No
I am postmenopausal
Yes No
Patient Signature: _________________________________________________________ Date: _______/______/______
Facility:
MRN:
DOS:
Referring:
Radiologist:
Delivery:
MRI SAFETY CHECKLIST AND PATIENT CONSENT FORM
PATIENT NAME
Patients:
Height:
PATIENT ID #
Weight:
Magnetic Resonance Imaging (MRI) provides your doctor with the latest technology available for imaging soft tissue of the
body. MRI utilizes a strong magnetic field and radio frequencies, both of which have, as of yet, not proven to exhibit any
long-term effects. Patients with cardiac pacemakers cannot undergo an MRI. Patients who have had surgery to implant
other metal devices in the body may be able to safely have an MRI if they do not have ferromagnetic devices placed at
critical locations. Patients exposed to metal grinding may have metal in their eyes. An x-ray may be necessary to detect the
location of metal objects in the body. Special attention must be given to possible magnetic sensitive devices that may be
placed within the body.
Please answer the following questions:
Yes
No Are you 60 years, or over? For contrast studies, if yes, current lab report needed and Rad approval
Yes
No Do you have a pacemaker?
Yes
No Do you have metal aneurysm clips?
Yes
No Have you ever had metal in your eyes?
Yes
No Have you ever been injured by shrapnel, BB, bullets, pellets, or any other pieces of metal that are still
present in your body?
If yes, did a doctor get it all out?
Yes
No Do you have any pins, screws, wires, metal rods or plates still present in your body?
If yes, explain what, which one, and location?
Yes
No Have you ever had head, eye, ear or heart surgery?
If yes, where, when, and what kind of surgery?
Yes
No Are you claustrophobic? If yes, have referring physician order medication
Yes
No Are you pregnant, or is there a chance that you could be pregnant? (No IV contrast if pregnant)
Yes
No Are you breast feeding? (If breast-feeding, IV contrast patient must wait for 24 hours after)
Yes
No Moderate to end stage kidney/liver disease? (If yes, we cannot administer contrast)
Yes
No History of Hypertension? For contrast studies, if yes, current lab report needed and Rad approval
Yes
No History of Diabetes? For contrast studies, if yes, current lab report needed and Rad approval
Yes
No Have you had any X-Rays, Cat Scans, MRI’s related to the exam ordered?
If yes, these films must be brought with you on the day of your exam
Please place a check mark by the following items that apply to you.
Aortic, carotid or arterial clips
Hearing aids
Artificial heart valve
Inner ear surgery
Artificial eye or limb
Insulin or infusion pumps
Brain surgery
Intrauterine Device (IUD) - contraceptive
Bone pins, screws, or joint replacement
Neurostimulators
Bridge work, dentures or partial plates
Permanent cosmetic eye lining or tattoos
Carotid clips
Prosthesis (eye, penile, etc.)
Cochlear or inner ear implants
TENS unit
Ear shunts
Wire mesh, wire sutures, staples
Electronic monitoring devices
Bone growth stimulators
Harrington (spinal) rods
Any implant held in place with a magnet
Arterial or venous catheters
I have reviewed the above list and have informed the staff of scheduled facility of any possible metal within my body. I
understand the risks and hazards associated with inaccurate information. The MRI exam may require an intravenous
injection of contrast or medication. The introduction of contrast or drugs into the body, rarely cause mild to severe reaction.
Your signature indicates that you understand the above mentioned information and all your questions have been accurately
answered and that you are giving our facility consent to perform an MRI exam, including the possible injection of a contrast
agent and/or medication as deemed necessary by the radiologist.
Patient Signature:
Date:
Medical Staff Signature:
Date:
(or legal guardian if minor)