If you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study.

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A Note to Our Patient: Your physician will be receiving a copy of your results via fax within two business days. Please contact your physician to go over your results and to obtain a copy of your report. A copy of your report may also be faxed to any physician that you request. ************************************************ We do our best to confirm your insurance requirements, however we do advise that you become familiar with your particular plan requirements as well (authorizations, referrals, pre-certifications, etc.). Unpaid amounts become the patient s responsibility. If you have a copayment, it is due at the time of service. ************************************************* If you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study. If your physician requires a copy of your images please inform the technologist at the time of your procedure. Additional CDs are charged at $5.00 per copy. Film is charged at $5.00 per sheet. A COPY OF YOUR PATIENT RIGHTS IS MADE AVAILABLE TO YOU AT THE TIME OF YOUR VISIT. (Please refer to the bottom of your clipboard or ask the front desk for a copy). Signature Date If you would like to receive updates from us in the future, please provide your e-mail below: (Please note: reports and personal information cannot be faxed or e-mailed.)

MEANINGFUL USE REQUIRED INFORMATION Patient ID: Patient Name: Patient DOB: Height Weight Gender M or F (circle one) Patient Race (check all that apply) Asian White Black/African American Other American Indian/Alaskan Native Native Hawaiian/Pacific Islander Patient Ethnicity (check one) Hispanic or Latino Non-Hispanic or Latino Blood Pressure Smoking Status (check one) Every day smoker Current some day smoker Smoker, current status unknown Former smoker Never smoker Unknown if ever smoked Vaccinations (Please check all that you have had) Flu Vaccination Pneumonia Vaccination Childhood Vaccinations Please list any known medical conditions/problems (such as asthma, diabetes, high blood pressure, ETC ) (use back if needed): Please list medications currently taken (use back of page if needed): Please list any known drug allergies (use back of page if needed): Lab Results: BUN Creatinine EGFR List any Stents, Valves, Pacemakers, Implants, ETC., Initials: Date

OPEN MRI AND DIAGNOSTIC IMAGING OF WALL Acknowledgement of OPEN MRI AND DIAGNOSTIC IMAGING OF WALL notice of HIPAA Privacy Name of Patient Date of Birth Signature of parent/guardian Designation of certain relatives, close friends and other caregivers: I agree that Open MRI and Diagnostic Imaging of Wall may disclose certain health information to a family member, close personal friend or other caregivers, since such person is involved with my health care. In that care, Open MRI and Diagnostic Imaging of Wall will disclose only information that is directly relevant to the person s involvement with my healthcare. I wish to be contacted in the following manner (check all that apply): Home telephone number: OK to leave message with detailed information* Leave message with call back number only OK to mail to my home address as listed on patient registration sheet Work telephone number: OK to leave message with detailed information* OK to leave message with call back number * Detailed information includes and not limited to reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. I designate the following persons listed below as persons involved with my healthcare, for the purpose of the practice making the limited disclosures as described above. I understand that I am not required to list anyone. I also understand that I may change this list at any time. ****PLEASE NOTE*** WE WILL NOT RELEASE INFORMATION TO ANYONE WHO IS NOT LISTED ON THIS FORM The privacy rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure of, and request for, patient health information to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the patient/parent/guardian. Healthcare entities must keep records of protected health information disclosures. Uses and disclosures for treatment, payment and healthcare operations may be permitted without prior consent. Signature of patient/parent/guardian Date

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