EFTA00282926.pdf

EAST RIVE R MEDICAL IMAGING, PC Date: 10/14/2015 Patient Name: EPSTEIN, JEFFREY PATIENT INFORMATION RECORD Medical Record Number #: 0315192 Social Security it: 090.44-3348 Address: Apt/Unit/Suite: City. SAINT THOMAS State: VI Zip: 00802 E-Mait Date of Birth: 01/20/1953 Primary Phone it Please validate your referring physician and contact information by marking the check boxes below. K Referring Physician: MOSKOWITZ BRUCE W. M D. M.D. K Referring Physician's Address: 11 N LAGLER DRIVE SUITE 7100 WEST PALM BEACH, FL 33401 K Referring Physician's Phone: Your referring Physician that has ordered this procedure will receive reports, films and/or CD (their preference). Please indicate by marking In the check box if you would like any additional processing to yourself or other physicians Additional Physicians Name: Address: Additional Reports To: Address: K Report Only (No Charge) K Report & CD ($26.00) K Report & Films ($200.00) Insurance Information Insurance Company. Group it: Insured's Name: Insured's DOB: Insured's ID#: Relation to patient: Do you have supplemental/secondary insurance? K Yes K No If yes, Insurance Company: Insured's ID it: Has your insurance changed since your last visit? K Yes K No (if yes, please fill out insurance Information above and supply your new insurance card(s) to the front desk receptionist.) EXAMS TODAY Pate / Time Exam Code Referring Name Accession 10/14/20157:30 AM EDT MRLSPNI MOSKOWITZ, BRUCE W, M.D 6784742 PAYMENT IS DUE AT THE TIME OF SERVICE K Cash K Check K Mastercard K Visa K Amex K Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: £LLbh£LZLZ 643etal leoPaN Jame! 1823 Nd LL N L SLOZ1£L/LDO EFTA00282926 EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Date: 10/13/15 Patient Name: EPSTEIN, JEFFREY Medical Record Number ft 0315192 Do you have any relevant outside studies (films/CD) with you? K Yes K No If Yes, please check the box as to how you would like your outside images returned K Upload CD to our system and take back with you K Return CD/Film to my home address on file K Return CD/Film to my referring physician Patient Signature Front Desk Receptionist Name Front Desk Receptionist Signature 6/Z £LLhh£LZLZ atn5etui ienIpaky iancti 1ss3 Vdd LI- 9Z L SLOZ1£L/LoO EFTA00282927 EAST -RIVER MEDICAL IMAGING. PC ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I. EPSTEIN, JEFFREY , have received the Notice of Privacy Practices from East River Medical Imaging, PC. PATIENT SIGNATURE 10/13/15 In lieu of patient signature, I, , a staff member of East River Medical Imaging, PC state that the patient named above has been given our current Notice of Privacy Practices. STAFF SIGNATURE DATE PATIENT NAME EPSTEIN, JEFFREY 0315192 6/£ £LLPPELZLZ u!0etui Ropaky JaApti 18,33 Wd LL '9Z L SL0Z/£L/L0O EFTA00282928 ,EAST RIVER PATIENT HEALTH HISTORY - MEANINGFUL USE MEDICAL IMAGING, PC Patient Name: EPSTEIN. JEFFREY MRN #:0315192 Age: 62 Years DOB: 01/20/1953 Sex: It Male K Female Exam Date: 10/14/2015 Height: Feet nches Weight: lbs Is English your Preferred Language? K Yes If not, please specify your preferred language: K No What Is your ethnicity? K Hispanic or Latino K Not Hispanic or Latino K Unknown K I choose not to specify What is your race? K African American K American Indian/ Alaskan K Caucasian K Asian K Hawaiian/ Pacific Islander K Other K Unknown K I choose not to specify What is your current tobacco smoking status? K Never a smoker K Current every day smoker K Former smoker K Current status unknown K Current some day smoker K Unknown if ever smoked Are you taking any medications? If so, please list: (Name / Dose) Dosage Name: Name: Name: K Yes K No Name: Name: Name: Dosage Are you allergic to any of the following medications/drugs? K No Known Drug Allergies K Penicillin K Benadryl K CT Contrast (iodinated Contrast) K Versed K Fentanyl K MRI Contrast (Gadolinium) K Xanax K Epinephrine K Barium K Sulfa K Other If Other Drug allergies, Please List Why did you opt for paper forms? K I prefer paper forms K I was not offered the iPad K I don't like technology K Other 6/P El LIPPELZLZ u!0etul Papaw JaNei Ise3 Meaningful Use Form 2013 v 2.0 Nd LL '9Z L SL0Z/£L/L°O EFTA00282929 EAST RIVER MEDICAL. IMAGING. PC MAGNETIC RESONANCE IMAGING (MRI) Patient Name: EPSTEIN, JEFFREY MRN #: 0315192 Exam Code: MRLSPNI Age: 62 Years Sex: M Height Feet Inches Weight: lbs Exam Date: 10/14/2015 Referring Physician: MOSKOWITZ, BRUCE W, M.D. M.D. Acc# 6784742 IMPORTANT: Please notify the receptionist if you answer "YES" to any of the questions below. The receptionist will inform the technologist/radiologist of your response. YES NO PLEASE CHECK: O K O O O O YES O K Have you had metal removed from your eyes? Have you been shot with bullets, BB's or shrapnel? Are you pregnant? Are you nursing? Are you on hemodialysis or peritoneal dialysis? Do you require oxygen or an inhaler? Do you have renal disease? If yes please describe Are you wearing any metallic items? Any surgery on the area to be imaged? If yes, when? Any surgery on your eyes, ears brain or heart? DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? Brain/Aneurysm Clips Pacemaker, Pacer Wires or Defibrillator if yes, make\ year Ear Implants or Hearing Aids Electrical Stimulators Implant/Prosthesis Infusion Pumps Coils. Catheters. Fitters or Wires in blood Artifical Limbs or Joint Replacement Tattooed Eyeliner Artificial Heart Valves Stents If yes, please provide date of implant Magnetic Dental Implants Transdermal Patches IUD Tissue expander for future implants Bone Stimulators. Insulin Pumps, or Mechanical Valves Programmable Shunts WARNING: Before entering the MR room, you must remove all metallic objects Including HEARING AIDS, DENTURES, CREDIT/BANK CARDS, watch, keys, cell phone, beeper, hair pins, barrettes, body piercing jewelry, money clips, magnetic strip cards, pens, pocket knife, and nail clipper. Please consult the technologist if you have any questions or concerns BEFORE you enter the MR room. Signature: Print Name: Date: 10/14/2015 Technologist's Use Only Patient Complaint/Diagnosis: Any previous imaging studies in this area? K YES K NO If yes, where? Technologist: Wet Reading K YES K NO Des Phone Number: 6/G MRI Clueslionnake 09-2013 £LLPPELZLZ au!tiewi iesipaw iannti Ise3 Nd LL '9Z L SLOZ1£LA3O EFTA00282930 EAST -RIVER MEDICAL IMAGING, PC SIGNATURE ON FILE/INSURANCE AUTHORIZATION CARD " I AUTHORIZE USE OF THIS FORM FOR ALL MY INSURANCE SUBMISSIONS; * I AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANY(S); * I UNDERSTAND I AM RESPONSIBLE FOR MY BILL * I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING ME OBTAIN PAYMENT FROM MY INSURANCE COMPANY(S); * I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR: AND * I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. PATIENT NAME EPSTEIN, JEFFREY ID NUMBER: DATE: 10/14/2015 PATIENT SIGNATURE• FOR OFFICE USE ONLY: MRN#: 0315192 Signature on Flie Form 02.2007 6/9 £lLPPELZLZ au!betui leopavu JaNei Isea INd L4 9Z L SL0Z1£L/L3O EFTA00282931 EAST RIVER MEDICAL IMAGING. PC MAGNETIC RESONANCE IMAGING (MRI) Patient Name: EPSTEIN, JEFFREY MRN #: 0315192 Exam Code: MRLSPNI Age: 62 Years Sex: M Height Feet Inches Weight lbs Exam Date: 10/14/2015 Referring Physician: MOSKOWITZ, BRUCE W, M.D. M.D. Acc# 6784742 IMPORTANT: Please notify the receptionist if you answer "YES" to any of the questions below. The receptionist will inform the technologist/radiologist of your response. YES NO PLEASE CHECK: K K Have you had metal removed from your eyes? K K Have you been shot with bullets, BB's or shrapnel? K K Are you pregnant? Are you nursing? Are you on hemodialysis or peritoneal dialysis? Do you require oxygen or an inhaler? Do you have renal disease? If yes please describe K K K K Are you wearing any metallic items? YES DODO 0000000000000 Any surgery on the area to be imaged? If yes, when? Any surgery on your eyes, ears brain or heart? NO DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? Brain/Aneurysm Clips Pacemaker, Pacer Wires or Defibrillator if yes, make\ year Ear Implants or Hearing Aids Electrical Stimulators Implant/Prosthesis Infusion Pumps Coils. Catheters, Filters or Wires in blood • Artifical Limbs or Joint Replacement Tattooed Eyeliner Artificial Heart Valves Stents If yes, please provide date of implant: Magnetic Dental Implants Transdermal Patches IUD Tissue expander for future implants Bone Stimulators, Insulin Pumps, or Mechanical Valves Programmable Shunts WARNING: Before entering the MR room, you must remove all metallic objects including HEARING AIDS, DENTURES, CREDIT/BANK CARDS, watch, keys, cell phone, beeper, hair pins, barrettes, body piercing jewelry, money clips, magnetic strip cards, pens, pocket knife, and nail clipper. Please consult the technologist if you have any questions or concerns BEFORE you enter the MR room. Signature: Print Name: Date: 10/14/2015 DODO 0000000000000 Technologists Use Only Patient Complaint/Diagnosis: Any previous imaging studies in this area? K YES K NO If yes, where? Technologist: Wet Reading K YES K NO Dr's Phone Number: MRI Questionnaire 09-2013 61L El LIPPELZLZ icoipaw JaApti 1993 Nd LL '9Z L SLOZ1£L/LDO EFTA00282932 10/14/15 7:30 am EAST RIVER MEDICAL IMAGING, PC Patient Experience Questionnaire Welcome to the East River Medical Imaging Patient Experience Questionnaire. This is an opportunity to openly share your thoughts about your recent experience. We will not ask any private questions- only about your experience at our medical offices. Your responses will help us strengthen our services to the high level of expectation that you deserve as our patient. 1. Was this your first visit to one of our four East River Medical Imaging offices? o Yes o No o Maybe (I have had radiology tests in the past, but I do not remember where) 2. How did you hear about East River Medical Imaging? o Referring Physician o Existing Patient/Retum Visit o General Internet Search (Google) o Family or Friend a Advertisement o Other: 3. Which East River Medical Imaging office did you have your test(s)? o 519 East 72nd Street o 523 East 72nd Street (Bjearjgo 523 East 72nd Street (C Level) o 3 East 75th Street o 430 East 59th Street o I do not remember 4. What test(s) did you have done at your most recent visit to East River Medical Imaging? o MR1 o CT o PET/CT o CT Myelogram o X-Ray / Fluoroscopy o Coronary CT Angiogram a Biopsy o General Ultrasounob Breast Ultrasound o Mammogram o Breast MRI K Nuclear Scan o Port Placement o PICC Line Insertion o Thoracentesis a Paracentesis o Dental Imaging o Bone Density Scan o I do not remember o Other 5. Did you or family member/friend schedule your appointment or did your referring physician's offi o I made the appoinhnerrb A friend/family made appointment o My physician/office 6. If YOU DID NOT MAKE APPOINTMENT, please skip this question. If you made the appointment, on a scale of 0 to 10 (with 0 being extremely low and 10 being extremely high), how would you rate the scheduling person at East River? Friendliness 0 1 2 3 4 5 6 7 8 9 10 Professionalism@ 1 2 3 4 5 6 7 8 9 10 6/9 £LLbh£LZLZ flugSewi iuo!Pati tonol lae3 Yid L4:9Z:IGL0Z/£1/OO EFTA00282933 7. Were you immediately greeted by our front office staff in a friendly manner when you arrived? K Yes o No K I do not remember 8. Did your test(s) begin... K On or Ahead of Time K Less than 15 minutes late o 15-30 minutes late K 30+ minutes late 9. If your test began late, did our scheduling coordinator, front office staff or technologist provide a reasonable explanation? o Yes K No n I do not remember 10. Did the technologist or radiologist explain the details of the test in a clear manner? o Yes K No K I do not remember 11. Were you made to feel comfortable throughout the test by the technologist or radiologist? K Yes K No 12. Based on your OVERALL experience at East River Medical Imaging, how likely is it that you wou recommend our office to a friend, family member or colleague? Please provide your honest answer a scale between "0" and "10" with "10" being "extremely likely to recommend" and "0" being "n( very likely to recommend." 0 1 2 3 4 5 6 7 8 9 10 13. Is there anything that we can do to ensure you receive the highest standard of medical care at our offices? What could have made your test experience better? We appreciate your honesty. 14. If you would like a member of our management team to contact you regarding your experience, please provide your name: Preferred Phone or E-mail: 6/6 £LLPPELZLZ au!0etui iospoky 18,33 Wd LL '9Z L SLOZ1£L/L0O EFTA00282934