Paperwork for Appointment Scheduled

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Insurance information

PROCEDURE SCREENING FORM

If yes, please list

MRI

CT/CAT Scan

X-Ray

Ultrasound

Nuclear Medicine

Other

For female patients

MRI WARNING: Certain implants, devices, or objects may be hazardous to you and/or may interfere with the MR procedure (i.e., MRI, MR angiography, functional MRI, MR spectroscopy). Do not enter the MR system room or MR environment if you have any question or concern regarding an implant, device, or object. Consult the MRI Technologist or Radiologist BEFORE entering the MR system room. The MR system magnet is ALWAYS on.

Please indicate if you have any of the following:

IMPORTANT INSTRUCTIONS

Before entering the MR environment or MR system room, you must remove all metallic objects including hearing aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paperclips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners, & clothing with metallic threads.

Please consult the MRI Technologist or Radiologist if you have any question or concern BEFORE you enter the MR system room.

NOTE: You may be advised or required to wear earplugs or other hearing protection during the MR procedure to prevent possible problems or hazards related to acoustic noise.

I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form and regarding the MR procedure that I am about to undergo.

PATIENT HIPAA CONSENT FORM

The Department of Health and Human Services has established a "Privacy Rule" (HIPAA) to help ensure that personal and medical information is protected. The privacy rule was also created to provide a standard for health care providers to obtain their Patients' consent for use and disclosure of health information to carry-out treatment, payment, or health care options.

As our patient we want you to know that we respect the privacy of your personal medical information and will do all we can to secure and protect that privacy. When it is appropriate and necessary, we provide the minimum information necessary to only those we feel are in need of your health care information; information about treatment, payment or health care operations in order to provide health care that is in your best interest.

We may have indirect treatment relationships and may have to disclose personal health information for purposes of treatment, payment, or health care operations, these entities are most often required to obtain patient consent. You may refuse to sign the Patient Consent Form allowing us to release your Personal Health Information (PHI), but this must be in writing; we have the right to refuse to treat you should you choose to refuse to disclose your PHI. If you choose to give consent in this document, at some future time you may request to refuse all or part of your consent. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with our Facility Manager. You have the right to review our privacy notice, request restrictions, and revoke consent in writing after you have reviewed our privacy notice.

I understand that I have been informed (read and understand) the HIPAA requirements, give consent for treatment, and will allow the release of medical information to:

PAYMENT POLICY

In order to achieve the goal of providing the best possible medical service to you at the lowest possible cost, we need your assistance and agreement to our payment policies. In almost all cases we will readily process your claim directly with your insurance plan. In a few instances we encounter some difficulty in that process and much of what follows deals with those exceptions. While we do not expect any difficulties with your claim, we do have to apprise you of our policy in those instances.

• By signing this form, you agree to assign to Open MRI, for this visit/exam(s), any and all health care benefits to which you are entitled under any policy of insurance (hospitalization, major medical, workers’ compensation, or any other insurance or benefit plan) and authorize, to the extent permitted by law, payment of those benefits directly to OSMRI. We will protect the privacy of your health information and will not use it or disclose it except in a manner that is permitted by state and federal law.
• Your plan may require approval (pre-authorization or “pre-cert”) from your insurance plan prior to your exam. Usually this must be obtained by the referring physician’s office, although sometimes Open MRI is permitted to obtain this. OSMRI cannot always apprise you if your policy requires prior authorization; however, we will inform you prior to your exam if pre-authorization was obtained. You should verify, prior to your exam, what the requirements of your plan are for pre-authorization as they vary widely with insurance companies and even within their different plans and policies. At the same time, you should determine and verify costs of care that your insurance company determines are not covered, or denied, for any reason, whether or not pre-authorization is required or obtained under your insurance policy.
• By signing this form, you have been advised that your insurance company may determine, even after they provide pre- authorization for your exam, that the services provided (or to be provided) by Open MRI during your visit are not covered under your policy, and you agree that, if your insurance company determines that any services are not covered, you shall be responsible for, and shall pay for, the cost of any such services.
• If you have health care benefits, Open MRI will submit a claim to your insurance company on your behalf. However, you are required, and you agree, to pay at the time of service any required co-payments, co-insurance and/or deductibles, as well as charges for services not covered by insurance, outstanding balances, and delinquent accounts. If your insurance plan is unable to provide this information to you, we can make a good faith estimate for you based upon our experience with similar plans.
• If you do not have health care benefits, you agree to pay at the time of service all charges as well as any outstanding balances and delinquent accounts, you have agreed to with Open MRI.
• Open MRI allows more than the legal and customary amount of time after filing a claim to be reimbursed by insurance companies. If Open MRI has not received a response within this prescribed time, and in no event more than 75 days of having filed a claim for your exam, we will assume that the visit is not covered and is, therefore, your responsibility. At that time, to the extent permitted by law, we will bill you for the visit charges. Questions regarding non-payment by your insurance company should be directed to your insurance company, not Open MRI, as your coverage, or contractual relationship, under your policy is between you and your insurance company and Open MRI is not privileged to intervene. Usually, contacting your insurance company directly will solve any issue, although you may need to persist to resolution.
• You will be billed for any remaining unpaid balances deemed by Open MRI or your insurance company to be your responsibility. Unless you otherwise request, all bills and other communications from Open MRI or your insurance company to be your responsibility. Unless you otherwise request, all bills and other communications from Open MRI will be sent to your address of record at Open MRI and will be in the name of the patient/guarantor who initially established your account. You are responsible for notifying us if you wish for a different address or name to be used. You are responsible for paying the bill in full unless special arrangements have been approved in advance. There is a fee of $25 for returned checks, or the maximum state rate if less. Delinquent accounts will be turned over to a collection agency at which time you will be responsible for collections charges and all associated legal fees in addition to the amount owed.

*A Guarantor is the individual who accepts financial responsibility for services rendered to the patient. The Guarantor may be the patient, a family member, or a non-family member. In the event the patient is a minor or legally dependent person, then the guarantor must have the authority to take action on the patient’s behalf. By signing this form as “Guarantor” on behalf of a minor or legally dependent person, you represent to Open MRI that you have such authority. The terms “you” and “your” as used in this document mean the patient’s Guarantor.

EXAM HISTORY

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