Mobile Mammo Registration Instructions
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- Alaina Alannah Shepherd
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1 Mobile Mammo Registration Instructions 1. Call to schedule your Fill out the following forms Note: All forms must be completed even if you were a previous patient on RRC Mobile Mammo prior to your upcoming appointment 3. Remember to bring your photo ID and insurance card(s) on the date of service. Kindly, call our scheduling department at Radiology Regional Center at to confirm availability of your requested time, date and location of the venue of your choice. Same day appointments are available.
2 Mobile Mammo Meaningful Use Questionnaire & Patient Router Meaningful Use is a federally mandated government program. The initiative is aimed at making it easier for physicians to share information and improve the overall healthcare experience for patients. As part of this initiative, Radiology Regional Center is required to gather information for compliance with the Meaningful Use guidelines. All information supplied becomes part of your Electronic Health Record (EHR) with Radiology Regional Center. Certain questions can be declined and choices are limited to those that are standardized by national healthcare agencies. If you have additional questions please visit the Office of the National Coordinator for Health Information Technology at and search Meaningful Use. Today's Date Patient Name: DOB: (Last, First, Middle) Local Address: City: State: Zip Code: Home Phone: Alternate Phone: Emergency Contact Name: Phone Number: Physician (1): Physician (2): Patient s Address: Your address is strictly for online access to your reports and health history via the Radiology Regional Center patient portal. Your address will not be sold to a third party or receive spam. Check here if you would like to receive monthly updates and promotional specials from Radiology Regional Centers and our Mobile Mammo. Gender: Male Female Marital Status: Married Single Widow Divorced Smoking Status: Every day smoker Occasional smoker Former smoker Never smoked History of Breast Cancer: Self Parent Sibling Child Unknown Breast Implants: Yes No Mammogram History: Is today s visit your first mammogram? Yes No If no, provide the name and address of the facility where you received your most recent mammogram. Date of your last mammogram: (mm/dd/yyyy) Patient Signature: Date: For Office Use Only: Date data entered: Data entered by: REV:12/09/15, 02/03/16 RF MM
3 Authorization for Medical Services 1. Legal Relationship Between Radiology Regional Center and Healthcare Practitioner. Healthcare practitioners involved in your care may be employees or contractors of Radiology Regional Center. I understand that certain healthcare practitioners furnishing services to me including, but not limited to, the anesthesiologist, surgeon, and the like, are independent contractors and are not employees or agents of Radiology Regional Center. I understand that there may be a separate charge from these physicians and healthcare professionals for their services. 2. Release of Information. I authorize Radiology Regional Center and any healthcare practitioner involved in my care to release my medical information and supporting documents of same, as compiled in my medical record during this outpatient visit, in accordance with HIPAA 45 CFR Parts 160 & 164 unless otherwise prohibited by the completion of a PHI Special Restriction Request form by the patient or patient s representative. I acknowledge that data from my medical record will be accessible to all healthcare providers participating in my healthcare treatment including, but not limited to, physicians, nurses, and technicians at Radiology Regional Center, practice(s) from which I was referred and/or physician(s) to whom I am referred for further treatment. I further acknowledge that my medical records will be utilized as part of Radiology Regional Center s utilization review, performance improvement, peer review and similar processes and studies. I also acknowledge that my medical record will be made available to government agencies as required by law. Information contained in my medical record may be extracted and compiled for research purposes and the aggregated results (which will not individually identify me) may be released to the public. I acknowledge that medical records at Radiology Regional Center may be stored electronically and may be made available through computer networks to Radiology Regional Center personnel, as well as physicians involved in my care, and their offices. I also acknowledge that, should I be treated at another facility in the area, whether or not affiliated with Radiology Regional Center, my medical record may be made available electronically or otherwise, to the other facility, including physicians involved in my care and their offices. This will assist my physician and other caregivers in reviewing past treatment, as it may affect my condition and treatment at that time. I authorize Radiology Regional Center to request pertinent medical information and supporting documents from any healthcare providers participating in my healthcare treatment. 3. Assignment of Benefits. I agree to assign all right, title, and interest in all benefits payable for the healthcare rendered, which are provided in any and all insurance policies and health benefit plans from which my dependents or I are entitled to recover. The assignment of benefits allows Radiology Regional Center and/or its healthcare practitioners to be paid directly by my health insurance carrier or other health benefit plan for the services Radiology Regional Center and/or its healthcare practitioners provide to me, my minor child, or other person(s) entitled to healthcare benefits for this admission. The assignment and transfer shall be for the purpose of granting Radiology Regional and/or its healthcare practitioners an independent right of recovery against my insurer or health benefit plan, but shall not be construed as an obligation of Radiology Regional Center and/or its healthcare practitioners to pursue any such right of recovery. 4. Medicare Patients. I certify that the information given by me in applying for payment under Title XVIII or Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for the claim for this admission, or a related Medicare claim. 5. Consent to Medical or Surgical Treatment. I, the undersigned, consent to the procedure(s) that may be performed during this office visit, including emergency treatment or services, and which may include, for example, laboratory procedures, x-ray examination, diagnostic procedures, medical, nursing or surgical treatment or procedures, anesthesia, or other services rendered under the general and special instructions of the healthcare practitioners involved in my care. In the event an employee is accidentally exposed to my blood/body fluids, I hereby consent to testing of my blood as deemed necessary by Radiology Regional Center or my attending primary care physician, to include hepatitis and HIV testing. I also acknowledge that no guarantee or warranty has been made by the healthcare practitioner involved in my care or Radiology Regional Center as to the results of any treatment or diagnostic or operative procedure which may be given or performed. 6. Personal Valuables. I hereby release Radiology Regional Center and its healthcare practitioners from all responsibility relative to the loss of or damage to money and/or valuables and/or property while receiving services at Radiology Regional Center s facility. 7. Financial Agreement. I, the undersigned, agree, whether I sign as a parent, guardian, spouse, agent, guarantor, or as a patient, that in the consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account of Radiology Regional Center in accordance with the regular rates and terms of Radiology Regional Center. Should the account be referred to an attorney or collection agency for collection, I shall pay actual attorney s fees and collection expenses. Each of the undersigned hereby consents to Radiology Regional Center s inquiries into his/her credit history in conformity with legitimate business needs and applicable laws, rules and regulations. Each of the undersigned agrees to pay all balances due and payable at the time of the patient s discharge from Radiology Regional Center. Each of the undersigned agrees that Radiology Regional Center may, with or without notice, assign, transfer and convey to any agency or attorney, its right, title and interest in any balance due after the patient s discharge. If suit is filed, the undersigned agrees to pay whatever additional costs, damages, fees and expenses are incurred in pursuing such claim, which may be determined as reasonable, by the court. 8. Consent to Receive Communication. If at any time I, or a person I am responsible for, provides contact information (a wireless or landline telephone number or mailing address) at which I may be contacted, I consent to receive communication in any manner, including, but not limited to, automated s, voice mails, written statements, texts, autodialed calls and prerecorded messages, which could result in charges to me. This consent to receive communication may pass on to Radiology Regional Center s successors and assigns, other medical providers used during the course of treatment, affiliates, agents, and independent contractors, such as servicers and collection agents. I understand that my contact information may be used for treatment, payment, and healthcare operations purposes. Radiology Regional Center does not sell its patient lists or contact information. I acknowledge that I am an authorized user of this contact information and that I have permission to use said contact information from the actual current subscriber of the information. It is my responsibility to update this healthcare provider with new and updated contact information and that, if I fail to update this information, I will hold the healthcare provider harmless for untimely notifications. Phone#1 Phone#2 I understand that I can change my mind by notifying optout@radiologyregional.com. 9. Adverse Benefit Determination. Radiology Regional Center is allowed full discovery of any and all information, documentation, policies, procedures and resources used by my health insurance carrier or other health benefit plan to perform an adverse benefit determination, as defined in 29 CFR of my covered health benefits. Radiology Regional Center is authorized to represent me in any and all federal lawsuits against my insurance company pursuant to ERISA. Radiology Regional Center is hereby authorized to initiate on my behalf any complaints regarding my healthcare benefits or adverse benefit determinations as defined in 29 CFR , with the State Insurance Commissioner for a possible violation of state insurance laws or the Employee Benefits Security Administration and the Secretary of Labor as it pertains to ERISA, specifically 29 USC 1003(a) and 1144(a). I hereby certify and state that I have read, and that I fully and completely understand the above Authorization for Medical Services, and that I have signed this Authorization for medical services knowingly, freely, and voluntarily. Date: X X Patient/Spouse/Parent/Guardian Signature Print Name Relationship to Patient REV06/30/14, 03/23/15, 11/15/17, 04/05/18, 07/11/2018 RF72B
4 Acknowledgement of Receipt of Notice of Privacy Practice By signing this form, you acknowledge that you have received or have been informed that you have the right to receive a copy of Radiology Regional Center Notice of Privacy Practice. This notice is available in hard copy by verbally requesting a copy at the front desk of any Radiology Regional Center facility or by submitting a request in writing to the HIPAA Privacy Officer at Radiology Regional Center, 3660 Broadway, Ft. Myers, FL You may also view and/or print a copy of the Notice of Privacy Practice by visiting Radiology Regional Center website at select the About Us tab and click on the Privacy Policy option. Patient Signature: Date: Print Name: Date of Birth: Guardian/Representative Signature: Date: Relationship to Patient:
5 Protected Health Information (PHI) Disclosure Authorization RRC may leave detailed messages at the following: * Telephone Number(s): Emergency Contact Name: Phone: Patient Address: By providing your address, you agree to receive notices from RRC, including notifications regarding your patient portal account. If you register for the portal with a shared account, please be advised that all users of that account may gain access to the medical information contained within the portal and will be able to access and/or reset the password for the portal. If you wish to protect your medical information from such access, do not register for the portal with a shared account or share your password with anyone. * ed records sent to an unencrypted address may be viewable by an unauthorized party. By selecting this delivery method you understand and accept the inherent risks of receiving records via to the address you specify. RRC may release any information (copies of exams, test results, appointment times & dates, medical & financial information) to the person(s) you list below. Name: Relationship: Create a 4 digit security code: (To access your account if requesting information by phone) I have received/ been offered a copy of the Radiology Regional Center Notice of Privacy Practices. I understand that Radiology Regional Center (RRC) may use or disclose my protected health information (PHI) for the purposes of medical treatment, payment, and healthcare operations, which may include students of healthcare provider training programs. RRC may also share information in the following circumstances: During a medical emergency, if the restricted information is needed to provide emergency care For certain public health activities For reporting abuse, neglect, domestic violence or other crimes For health oversight activities, law enforcement investigations, judicial or administrative proceedings For identifying decedents to the coroner, or determining cause of death For worker s compensation programs For uses or disclosures otherwise required by law For the Business Associates (BA) performing services on behalf of RRC as noted in the Notice of Privacy Practices * I understand that I can revoke this authorization at any time by written request to RRC and that it is otherwise valid for one year. I understand that RRC may not condition treatment, payment, enrollment or eligibility of benefits on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer subject to applicable privacy laws. If at any time I, or a person I am responsible for, provides contact information (a wireless or landline telephone number, address, ) at which I may be contacted, I consent to receive communication in any manner, including but not limited to; automated s, voice mails, written statements, texts, autodialed calls and pre-recorded messages, which could result in charges to me. This healthcare provider may pass this right on to its successors and assigns, other medical providers used during the course of treatment, affiliates, agents, and independent contractors, including, but not limited to, servicers and collection agents. This contact information may be used for treatment, payment, and operations. I acknowledge that I am an authorized user of this contact information and that I have permission to use said contact information from the actual current subscriber of the information. It is my responsibility to update this healthcare provider with new and updated contact information and that, if I fail to update this information, I will hold the healthcare provider harmless for untimely notifications. I understand that I can change my mind by notifying optout@radiologyregional.com. Patient Signature:_ Date: Print Name:_ Birth date: Guardian/Representative Signature: Date: Relationship to patient: PHI disclosure form Rev12/28/17
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