Letter module

Account #: _____________
Date: ______________
Patient's Name: _____________________________________________ Date of Birth: ______________Social Security: ________________
Guarantor Name: ______________________________________________ Address: ________________________________________ City______________________________State__________ ZipCode___________ Cell: ____________________ Work / Other: ____________________ Referring Physician: _____________________________________ Phone
______________________ Fax ___________________
Address: ______________________________________________City__________________________________State____________ZipCode ____________ Primary Insurance: ____________________________________Policy No: _________________________________ INS ACTIVE: ______ Secondary Insurance Name and Policy #: _________________________________________________________ INS ACTIVE: ______ Attorney Contact Name and Phone Number: ______________________________________________________________________________ We do require you to pay your co-payments and deductibles at the time of service. We accept cash, checks, Visa, Master Card, and American Express.
Please understand that any monies collected at the time of visit are only an estimated amount of your financial responsibility and do not represent the
total financial responsibility due for the services rendered. In most cases, we will bill your insurance for you. Please understand that this is a courtesy to
our patients, not our responsibility. Your insurance contract is between you and your insurance company. It is YOUR responsibility to understand the terms
and benefits, which are a part of your contract. If you are unsure what your benefits are, you should contact your benefits department for verification prior to
your visit.
I have read the foregoing, have received a copy thereof (upon my request), and I am personally empowered, or am duly authorized by the patient, as patient'sgeneral agent to execute the above, It is my responsibility to consult with my insurance company regarding payment and authorizations required prior to myvisit. I hereby assign to Professional Imaging Centers, Inc reimbursement benefits of all insurance policies and/or settlements otherwise payable to the patientfor service rendered. I authorize Professional Imaging Centers, Inc to submit claims to insurance companies plan administrators, and/or attorneys and to applyinsurance proceeds to Professional Imaging Centers, Inc. If refunds are due under the provision of such insurance policies, I also assign all rights, as theinsured, to bring an action against my insurance company for benefits due under the insurance policies.If your insurance company has not paid your bill in fullwithin 60 days, you will be expected to pay in full the balance. Any balance due from you after your insurance has paid will be due within 30 days from receiptof your statement. In the event of a large balance due, we can arrange a payment plan suitable for all parties concerned. _______________________________________________Patient's Signature_______________________________________________ Guarantor (if other than patient) Parent or Legal Guardian _____________________________________________FOR OFFICE USE ONLY_______________________________________________ Today's Financial Responsibility $______________ Previous Balance $__________________ Total Balance Due $_______________
Payment by ________________ Payment Amount $____________________ Balance Due $_________________
Cash, VS, MC, AMEX, Disc, Check/Check No.
BILLING COMMENTS:____________________________________________________________
CC REPORT TO: ____________________________________________________ PREVIOUS THYROID EXAMS ______________PREVIOUS BREAST U/S OR MAMMO _________ PREVIOUS PIC EXAMS _____________________________________________________________________________________________ INSURANCE VERIFIED _____________ FRONT DESK Exam(s) Performed: TECH ___________________ RAD ________________________
INTERNAL STUDY CODE
INTERNAL STUDY CODE
CT / MR CONTRAST CPT CODE ___________________
UNIT #: ___________________________ML
PROFESSIONAL IMAGING CENTERS, INC.
1049 WILLA SPRINGS DR., STE 1051
WINTER SPRINGS, FL 32708
Phone: (407) 657-7979
DISCLOSURE AUTHORIZATION FOR INFORMATION REQUEST
Patient's Name _______________________________________________
Date of Birth: _____________________
Pursuant to the Health Insurance Portability and Accountability Act (HIPPA), I hereby authorize the following providers:
(List all providers from whom information is being sought) to disclose the following protected health information to
Professional Imaging Centers and/or Professional Imaging Consultants.
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ □ Copies of any diagnostic imaging tests taken within the past seven years.
□ Medical history, including specific progress notes regarding any problems that would impact my surgery or □ Results of relevant diagnostic or laboratory tests.
□ Other: ____________________________________________________________________________________________ This protected health information is being used by the facility for the purpose of preparation for an outpatient procedure
at Professional Imaging Centers and/or Professional Imaging Consultants.
This authorization shall be in force and effect until: _____/_____/_______ I understand that, as set forth in the health care facility's Privacy Notice, I have the right to revoke this authorization, inwriting at any time by sending written notification to: Professional Imaging Centers -Attn: Privacy Officer
1049 Willa Spring Dr., STE 1051; Winter Springs, FL 32708
I authorize Professional Imaging Centers to release films and/or reports regarding my radiographic exams to treating healthcare providers thatwill be providing medical treatment or service to me.
I understand that a revocation is not effective to the extent that the health care facility has relied on the use or disclosure ofthe protected health information.
I understand that information used and disclosed pursuant to this authorization may be subject to re-disclosure by therecipient and may no longer be protected by federal or state law.
I understand that the health care facility will not condition my treatment on whether I provide authorization for the requested disclosure.
I hereby authorize Professional Imaging Centers, to release information and/or copies of my medical records to any guarantor of payment onmy account, any insurance company for which benefits have been assigned. I authorize Professional Imaging Centers to release copies of myfilm(s) to the following person(s) other than my referring physician: Name:_____________________________________________ Relationship: ______________________________________________ Name:_____________________________________________ Relationship: ______________________________________________ *Revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this *The Information released in response to this authorization may be re-disclosed to other parties *My treatment or payment for my treatment cannot be conditioned on the signing of this authorization ________________________________________________
_____/_______/_______
Signature of Patient or Personal Representative
___________________________________________________________
________________________________________________________
Print Patient's Name or Personal Representative
Description of Personal Representative's Authority
Fax Reports To: Professional Imaging Centers __________________________Attn: __________________________
Patient Will Pick- Up on_____________________________________________________________________________
Courier Will Pick- Up on ___________________________________________Courier Name_____________________
Account #:_____________________
PATIENT INFORMATION
Date:____________
PATIENT'S NAME: ______________________________________ DOB:
_____________________
FEMALE PATIENTS:
PREGNANT?
(circle one)
LAST MENSTRUAL PERIOD ______________________________________
With the full understanding of the above, I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy
suspected or confirmed at this time and I wish to have a radiographic examination performed now. There is a risk in the use of
radiation and the possiblity that it will harm a fetus; thus, if there is a chance that you are pregnant, you should not participate in
the study before having a test to confirm non-pregnancy. (______________) Please initial.
CIRCLE IF YOU HAVE OR HAVE EVER HAD:
ALLERGIC REACTION TO CONTRAST
TAKE GLUCOPHAGE,GLUCOVANCE, OR METFORMING
ALLERGIC TO IODINE/SHELLFISH
CARDIAC PACEMAKER
METAL IMPLANTS IN YOUR BODY
REMOVABLE
SICKLE CELL DISEASE
BRAIN ANEURYSM CLIP
HEAD SURGERY(BRAIN,EYES,EARS)
RENAL (KIDNEY) DISEASE
ELECTRICAL STIMULATOR METAL
SHRAPNEL/FRAGMENTS
DIABETES
TATTOO/PERMANENT MAKE UP
CANCER___________________________________________________________________________
HYPERTENSION/ HIGH BLOOD PRESSURE
WEIGHT: _______________________
SEX: __________________________________
WHAT KIND OF SURGERIES HAVE YOU HAD? (TYPE & DATE) ____________________________________________________________________
_____________________________________________________________________________________________________________________________________________
LIST ANY ALLERGIES:_____________________________________________________________________________________________________
LIST PRIOR EXAMS RELATED TO TODAY'S STUDY (FACILITY NAME,DATE,EXAM TYPE): ________________________________________
_____________________________________________________________________________________________________________________________________________
HAVE YOU BEEN TO OUR FACILITY BEFORE? ________ WHEN?: ___________________________________________________
Emergency Contact: ______________________________ Relation: _____________ Phone Number: ___________________
**You may be receiving an intravenous contrast media and/or oral contrast media to enhance the visibility of certain tissues.
Possible side effects include, but are not limited to: nausea,a warm flushed feeling, potential allergic reaction including, but not
limited to hives, wheezing, difficulty breathing in rare cases, anaphylactic shocks _________________________ (INITIAL)
**I,the undersigned, verify that all the answers I have provided are true to the best of my knowledge. I give Professional Imaging
Centers the permission to perform the examination(s) requested by my physician. I have read the above and fully understand its
contents and all my questions have been answered.
________________________________________________________
___________________________________________________
PATIENT'S
SIGNATURE
______________________________________________________________
_________________________________________________________
PARENT/LEGAL
GUARDIAN
RELATION
DO NOT WRITE BELOW THIS LINE
EXAM: MRI MRA CT CTA XRAY:_______________________________________________CONTRAST __________________________________
DX:___________________________________________________________________________________________ DOI:_________________________
SYMPTOMS:______________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
RADIOLOGIST: ___________________________ TECH: _________________________ PRIORS: ____________________________
COMMENTS: ____________________________________________________________________________________________________
THE ABOVE DOCUMENT WAS TRANSLATED BY ___________________________________________ ON ________________________________________________

Source: http://www.picfl.com/pdf/patient-forms.pdf