PATIENT REGISTRATION. Street City State Zip WORK INJURY/ ACCIDENT

Transcription

1 PATIENT REGISTRATION, Last First M.I. SEX: Male Female DOB: / _/ AGE: MARITAL STATUS: SS#: - - PHYSICIAN: ADDRESS: Street City State Zip (HOME) (WORK) TEL: - - TEL: - _- CELL: - _- PRIMARY INSURANCE: SECONDARY INSURANCE: EMERGENCY CONTACT:, Last POLICY NO.: POLICY NO.: EMERGENCY TEL: REPONSIBLE PARTY (IF OTHER THAN PATIENT) RELATIONSHIP: SS#: - - DOB: / / First WORK INJURY/ ACCIDENT IS THIS VISIT A RESULT OF A WORK INJURY? If yes, then: DATE INJURED: / / INDUSTRIAL CLAIM #: IS THIS VISIT A RESULT OF AN ACCIDENT? If yes, then: DATE OF ACCIDENT: / / ATTORNEY: TEL #: - - MEDICAL RELEASE/ AUTHORIZATION I, _, authorize Lakeside MRI & Diagnostic Center and its medical and technical staff to perform the necessary diagnostic and treatment procedures requested by my referring doctor. I also give my authorization to Lakeside MRI & Diagnostic Center to release any part or all of my medical records and general information obtained during my visit to this center to any insurance organization, my attorney and other medical personnel involved in my care or any other agency that may require my information. I further understand that this information is stored in an electronic medical records format and may be transmitted to my physician or authorized personnel only after proper identification and authentication. I authorize the release of any medical or other information necessary to process insurance claims on my behalf. I authorize that the payment be made directly on my behalf to LAKESIDE OPEN MRI &. I understand that I am responsible for my account whether my insurance covers it or not. I understand that all copayments, co-insurance, and deductibles are my responsibility and I agree to make full payment upon receiving the balance of my medical bill from Lakeside Open MRI & Diagnostic Center. I also authorize Lakeside MRI & Diagnostic Center to release this signature to the social security administration (Medicare) and other government agencies, Workers compensation, or billing agents. Referring Physician authorizes Lakeside Open MRI & Diagnostic Center to contact patient s managed care plan or other insurer on behalf of Referring Physician to pre-certify the patient for the procedure being requested and to provide scheduling services for the patient being referred. SIGNATURE DATE

2 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICIES Use and disclosure of protected health information is regulated by a federal law known as The health Insurance Portability and Accountability Act of 1996 (HIPAA). Under HIPAA, providers of healthcare are required to give patients an opportunity to review and/or obtain a copy of their Notice of Privacy Practices for Protected Health Information and make a good faith effort to obtain a written acknowledgment that this notice was received. I have been presented with a copy of LAKESIDE OPEN MRI & S Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. PATIENT SIGNATURE: DATE: / _/ ************************************************************************************************************************************ If signed by someone other than patient, please indicate relationship to patient: SIGNATURE: RELATIONSHIP: DATE: / / Optional: I understand the contents of the Notice, and I request the following restrictions(s) concerning the use of my personal medical information: X (Please Initial) ************************************************************************************************************************************ Internal Use Only: If the patient or patient s representative refuses to sign acknowledgement of receipt of notice, please document the date the notice was presented to patient and sign below. PRESENTED ON DATE: / / LAKESIDE REPRESENTATIVE: FAX PRIVACY WAIVER I understand that my medical records may be transmitted electronically by fax and may be received in error by a third party. In the event that this should occur, I absolve Lakeside Open MRI & Diagnostic Center of all liability. I give my consent to fax my records for the purposes of treatment, payment, or healthcare options, and I understand that I may withdraw this consent at any time in writing. Signature of patient or representative Printed name of patient or representative

3 PATIENT QUESTIONNAIRE MEDICAL HISTORY HEIGHT: WEIGHT: ARE YOU EXPERIENCING PAIN OR OTHER SYMPTOMS? ARE YOU BEING TREATED FOR ANY OTHER MEDICAL PROBLEM? HAVE YOU EVER BEEN DIAGNOSED WITH CANCER? YES NO If yes, please describe: HAVE YOU EXPERIENCED TRAUMA OR INJURY RECENTLY? YES NO If yes, please describe: HAVE YOU HAD ANY SURGERY? ARE YOU CURRENTLY TAKING ANY MEDICATIONS? YES NO If yes, please list: ARE YOU ALLERGIC TO: MEDICATIONS YES NO If yes, please list: OTHER YES NO If yes, please list: ARE YOU DIABETIC? YES NO If yes, what medication(s) are you currently taking for this condition? DO YOU HAVE HYPERTENSION? DO YOU HAVE A HISTORY OF RENAL FAILURE OR KIDNEY DISEASE? DIALYSIS? HAVE YOU EVER HAD A PREVIOUS REACTION TO ANY CONTRAST MEDIA? YES NO YES NO YES NO HAVE YOU HAD OTHER DIAGNOSTIC TESTS FOR THIS CONDITION? YES NO Where? When? What kind?

4 Please indicate if you have any of the following: YES NO If yes, explain Cardiac pacemaker Aneurysm clip (metal clips put around blood vessels during surgery) Electrical Stimulator for nerves, bone or brain Ear or Eye implants e.g. cochlear implants/or hearing aid Implanted insulin, drug or infusion pump Coil, stent, catheter or filter in any blood vessel Internal electrodes or wires IUD or diaphragm Orthopedic hardware ex. Artificial joints, metal plates, screws, or surgical staples, clips or metal sutures Any other type of prosthesis or implant? Gun pellets, shrapnel, bullets or metal fragments Have you had an MRI scan before? Are you claustrophobic? Have panic attacks? Have you ever been a welder, machinist, grinder or worked with metal without eye protection? Do you have any tattoos, tattooed eye/lipliner or body piercings? Do you wear dentures, a dental plate or braces (not fillings) Do you have any trans-dermal medication skin patches? Breathing problem or motion disorder Hearing aid (Remove before entering MR room) Female Patients Only: ANY CHANCE OF PREGNANCY? ARE YOU CURRENTLY BREAST FEEDING? YES NO YES NO I have read and understood the questions in this questionnaire and that the above responses are correct to the best of my knowledge. I understand that it is my responsibility to inform the Center of any metal fragments and/or devices that may be in my body and that by failing to do so may cause serious bodily injury or be life threatening. I agree that should I have any metal in my body and, after consultation with a physician, elect to proceed with the MRI, I agree to release the Center from any and all liability for any injury. SIGNATURE _ DATE DO NOT BRING ANYTHING INTO THE SCAN ROOM WITH YOU. Please remove all metallic objects including keys, hair pins, barrettes, jewelry, watch, safety pins, paperclips, money clip, credit cards, coins, pens, belt, metal buttons, pocket knife, & clothing with metal in the material.

5 PT ID#: PREGNANCY RELEASE FORM - MRI Thank you for coming to our facility and allowing us the opportunity to serve you. We sometimes ask for the cooperation of our patients by asking personal but necessary and important questions in order to provide quality care. 1. Are you pregnant or do you think you may be? No Yes 2. Have you recently had a pregnancy test? No Yes If yes, test date: Negative Positive Dr. 3. of Last menstrual period: / / Post Menopausal? No Yes 4. Are you taking oral contraceptives or receiving hormonal treatment? No Yes 5. Are you currently breast feeding? No Yes This exam uses magnetic fields and radio waves to image the body. There are no known harmful effects on the developing fetus or mother, however, long term experience is lacking. An MRI exam WILL NOT be performed during the first trimester of pregnancy. I understand there could be unknown risk to the fetus but by signing this form, I am agreeing to have this test. PATIENT S SIGNATURE: Tech Comments: