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.
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:
*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 ________________________________________________
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Material Safety Data Sheet Revision Number: 000.0 Issue date: 11/23/2010 1. PRODUCT AND COMPANY IDENTIFICATION Product name: Loctite Threadlocker Red 271 IDH number: 209741 Product type: Company address: Contact information: MEDICAL EMERGENCY Phone: Poison Control Center 1-877-671-4608 (toll free) or 1-303-592-1711 TRANSPORT EMERGENCY Phone: CHEMTREC 1-8