EFTA00299773.pdf

EAST RIVER MEDICAL IMAGING. PC Date: 06/05/2018 Patient Name: EPSTEIN, JEFFREY PATIENT INFORMATION RECORQ Medical Record Number #: 0315192 Social Security Address: 6100 RED HOOK QUARTERS Apt/Unit/Suite: APT B3 City: SAINT THOMAS State: VI Date of Birth: 01/20/1953 Zip: 00802 Primary Phone #: E-Mail: Please validate your referring physician and contact information by marking the check boxes below. 0 Referring Physician: MOSKOWITZ BRUCE W MO MD 0 Referring Physician's Address: 14j1 NORTH RtAGLER DRIVE SUITE_7100 WEST PALM BEACH. FL 33401 O Referring Physician's Phone: Your referring Physician that has ordered this procedure will reeoive reports, films and/or CO (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: 0 Report Only (No Charge) 0 Report & CD ($25.00) 0 Report & Films (S200.00) Insurance InfoonatiOn Insurance Company: Group #: Insured's Name: Insured's D08: Insured's ID#: Relation to patient Do you have supplemental/secondary insurance? K Yes 0 No If yes. Insurance Company: Insured's ID #: Hoo your inauronce 'slimmed since your last vlSitt O Vet O No (if yes, please fill out insurance information above and supply your new insurance card(s) to the front desk receptionist) atilt= EXAMS TODAY Pate / Time Exam Code Referring Name Accession 06/05/2018 8:30 AM EDT MRCLAVL MOSKOWITZ, BRUCE W, M.0 7156124 PAYMENT IS DUE AT THE TIME OF SERVICE 0 Cash 0 Check 0 Mastercard K Visa 0 Amex 0 Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: goon/noon WI xv OZ:9 STOZ/OC/SO EFTA00299773 EAST RIVER MEDICAL IMAGING, PC OUTSIDE FILMS/CD FORM Oate: 5/30/18 Patient Name: EPSTEIN, JEFFREY Medical Record Number #: 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 0 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 gnarl znoa iVd KV OZ:8 9TOZ/OC/S0 EFTA00299774 , EAST .. DRIVER 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: 5/30/18 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 NAM C. FPSTFI N .IFFPRPV 0315192 CAAll /NUM 131 iVd XV OZ:9 STOZ/OC/SO EFTA00299775 00 00 t 000131 0 YES D NO EAST DERIVER MEDICAL IMAGING. PC MAGNETIC RESONANCE IMAGING IMRI) Patient Name: EPSTEIN. JEFFREY MRN #: 0315192 Exam Code: MRCLAVL Age: 65 Years Sex: M Height: Feet Inches Weight lbs Exam Date: 06/05/2018 Referring Physician: MOSKOWITZ. BRUCE W. M.D. M.D. Acc# 7156124 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: 0 0 Have you had metal removed from your eyes? D 0 Have you been shot with bullets, BB's or shrapnel? 0 0 Are you pregnant? 0 CI Are you nursing? 0 0 Are you on hemodialysis or peritoneal dialysis? 0 0 Do you require oxygen or an inhaler? CI 0 Do you have renal disease? If yes please describe 0 0 Are you wearing any metallic items? 0 0 Any surgery on the area to be imaged? If yes, when? CI 0 Any surgery on your eyes, ears brain or heart? 0 0 Have you had a Colonoscopy and/or Endoscopy within the last 6 weeks? If yes, date of exam YES NO DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? 0 0 Brain/Aneurysm Clips 0 0 Pacemaker, Pacer Wires or Defibrillator if yes, make\ year 0 0 Any Metallic fragment or foreign body CI O Ear Implants or Hearing Aids 0 C7 Electrical Stimulators 0 0 Implant/Prosthesis CI 0 Infusion Pumps 0 0 Coils. Catheters. Filters or Wires in blood 0 0 Artifical Limbs or Joint Replacement CI 0 Tattooed Eyeliner 0 O Artificial Heart Valves 0 0 Stents If yes, please provide date of implant: 0 Q Magnetic Dental Implants I= D Transdermal Patches CI D IUD 0 0 Tissue expander for future implants 0 0 Bone Stimulators. Insulin Pumps, or Mechanical Valves 0 D 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: 06/05/2016 Technologist's Use Only Patient Complaint/Diagnosis: Any previous imaging studies in this area? If yes, where? Technologist: Wet Reading K YES D NO Dr's Phone Number: MR1 Questionnaire 09-2013 YVI fit TZ:8 9TOZ/OC/S0 EFTA00299776 REAST IV MEDICAL imAGINGE. PAC 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 06/05/2018 PATIENT SIGNATURE' FOR OFFICE USE ONLY: MRN#: 0315192 Signature on Fife Form 02.2007 cAnn,ennna IVd x TZ:9 9TOE/OC/10 EFTA00299777