EFTA00306878.pdf

East Side Medical Radiology PLLC 170 East 77" Street - Lower Leval Mow York, NY 10075 Phone 212-369-9200 Date Patient Last Name Find Homo Address Apt 0 City State Zip Country Home Phone Work Phono Coil Phone Date of Birth SS0 Sex Male Female Emergency Contact Name Relationship Phone Name of Employer Employers Address Primary Insurance Name Policy Holder Name Policy Holder Date of Birth Policy tl Group Phone Number of Insurance Company Secondary Insurance Name Policy tl Group 0 Phone 0 of Secondary Insurance Company Policy Holder Name __ Policy Holder Date of Birth I authorized the release of any medical or other information necessary to process the claim for services rendered to mo. I also request payment of government benefits or commercial insurance hemline to myself or the party who accepts the assignment below. Name Signature. - - -- Date I authorize paymont of medical benefits to the physician or medical practice for the services rondorod. Name Signature Date EFTA00306878 East Slily Medical Rudloff I'I,I.f Sieved D. Wolff M. 171) r. 77". st., 'St". York %% 10073 (212 )3119-92D0 NIPAA PRIVACY NOTICE • I acknowledge that I hove been given a copy of the Practice's *HIPAA Privacy Notice" which describes the Practice's obligations to ensure the privacy of my health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my health information for treatment, payment end health care operations. I know that I have the right to review the Practice's HIPAA Privacy Notice and to ask questions about it. I understand the Practice Is required to maintain the privacy of my health Information In accordance with the terms of its HIPAA Privacy Notice. • I further acknowledge that the Practice can change its HIPAA Privacy Notice In the future, and that I can receive a copy of the Practice's current Privacy Notice at any time by contacting the Privacy Officer. • I understand that I have a right to request that the Practice restrict its uses and disclosures of my health information for treatment, payment, or health core operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to my requested restrictions. • I do del request any restrictions on the Practice's use or disclosures of my health information for treatment, payment or health care operations. (initial). • I request specific restrictions, as listed below, crinival tthe )prectiCe's use or disclosures of my health information for treatment, payment or health care operations. • By signing this form, I consent to the Practice's use end disclosure of my health information for treatment, payment and healthcare operations. I understand that I have the right to revoke this consent at any time in writing, but if I do, my revocation will not influence any actions the Practice has already taken in reliance on this consent Authorization to Obtain or Release Medical Records from Medical Providerq I hereby authorize East Side Medical Radiology PILO to obtain any and all medical records specifically related to my current condition from any physician, hospital, or other health care professional that has provided medical care to me In relation to my current condition in the past. (initial). I also authorize the Practice to release any and all medical records, physically or verbatly, concerning my care to the following specified parties: Referring Physician Insurance Company, Medicare, Medicaid, Third Party Administrator, Managed Care Company Consent Required Consent Required Additional Party Name Relationship to Patient 2. 3. 4. Authorization to Obtain or Release Medical Information to Individualffamily Members In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your medical conditions, the law stipulates that these rules may be waived. (initial) I authorize the Practice to release any or all Information, in any form of communication, concerning my medical care as set forth above. Patient's Signature: Print Patient's Name Date: EFTA00306879 Summary Notice of Privacy Practice* THIS SUMMARY DESCRIBES HOW MEDICAL INFORMATION ABOUT OUR PATIENTS MAY BE USED AND DISCLOSED AND HOW PATIENTS CAN GAIN AACCESS TO THIS INFORMATION. PLEASE REVIEW THE SUMMARY. THE FULL NOTICE IS AVAILABLE UPON REQUEST. Our practice Is required by law to maintain the privacy of confidential information and to provide Individuals with notice of its legal duties and privacy practices with respect to such information. We reserve the right to change the terms of notice and make the new notice provisions effective for all confidential information we maintain. We will provide written revised notice. Uses and Disclosure of Protected Health Information (PHI) • You will be asked to sign a consent form which permits us to use your PHI for treatment, payment and health care operations. • Other uses of your PHI will be made only with your written authorization. • We may disclose information to a person or persons you identify. • We may disclose information in the event of an emergency and in a situation where we are unable to obtain consent from you due to your communication barriers. • We may contact you to provide appointment reminders, test results, or information about treatment alternatives or other health related benefits and services. In the event of your absence, we may leave a message at your home or office unless otherwise advised by you. Disclosures that may be made without your consent • Required by law • Public Health Issues • Communicable diseases • Health oversight • Abuse or neglect • Food and Drug Administration issues • Legal proceedings In response to court order • Law enforcement issues • Coroners, Funeral Directors, and organ donation • Research • Criminal activity • Military activity and National Security • Worker's Compensation • Inmates • Required Users Patient Right* • Inspect and copy your protected health Information • Request restrictions of your protected health information • Receive confidential communications by alternative means or at an alternative location • Request amendment of protected health Information • Receive an accounting of certain disclosures made by us • Obtain a paper copy of complete notice from us EFTA00306880 Name: Date of Birth: Height: Weight: Social Security #: Some of the following items may be hazardous to your safety or can interfere with you MRI/MRA examination. Please check YES or NO for each of the following items. YES NO Cardiac Pacemaker or Defibrillator Brain Aneurysm cip (s) Transdermal Patch: Nicotine / Nitroglycerine Shunts (e.g. Spinal / intraventrIcular/ VP shunt) Bone Growth /Fusion stimulator Neurostimulator Cochlear /Dior:ogle/Ear Implant Implanted Drug Infusion Device / Insulin Pump Electrodes (on body, head or brain) My Implant Held In Place by Magnet Carotid Artery Vascular Clamp Intravascular slants, filters, or coils Vascular Access Port and/or Catheter Swan-Ganz Catheter internal Pacing Wires My type of prosthesis: eye.perfile, etc Metal or Wire Mesh Imp ants Harrington Rods (spine) Joint Replacement Bone/Joint pin, screw, nail, wire, plate Body piercing (s) Tattooed Makeup (eyeliner, ups, etc) My Metal Fragments IUD or Diaphragm Hearing aid (remove before MRUMRA) Dentures (remove before MRINRA) Asthma or other breathing disorder Meaty Other: 1. What problems are you having that made the doctor order this study? 2. Have you ever been to the hospital for an invasive procedures or surgery? Yea / No Ql Reason 3. Have you ever had an accident that required metal fragments to be removed from your eye? 4. Women: Could you be pregnant? Yes / No 5. Do you have a history of kidney disease? Yes / No 6. Do you have sickle cell anemia? Yos / No 7. Have you had an allergic reaction that required emergency treatment? Yes I No 8. Do you or have you: High blood pressure? Yes I No Diabetes? Yes I No High cholesterol? Yoe I No Smoked tobacco? Yos I No 9. Do you have chest pain? Yes I No If yes: Is it substemal? Yes I No Is it brought on by exertion or emotional stress? Yos I No Is it relieved by rest or nitroglycerine? Yos / No Patient Signature: Date: MRI Screening Form: 10/22/12 EFTA00306881 INFORMED CONSENT FOR MRI CONTRAST INJECTION As part of your scan we may need to inject you with a contrast solution containing gadolinium. This clear, colorless liquid is removed from your body by your kidneys and will not alter the appearance of your urine. It will show up on images to provide important diagnostic information. During the injection, it is common to feel a cool sensation near the injection site or experience a slight metallic taste. These stop almost immediately after the injection is completed. Rarely, a more serious reaction can occur that could affect your breathing or lower your blood pressure. Your personal physician is aware of the risk of complications, but feels that the diagnostic information to be obtained outweighs the small risk of the injection. We take every precaution to obtain a good examination with maximum safety. There is some risk in not having the examination that your doctor has requested. If this examination is not done with this injection, your doctor may not be able to as accurately diagnose your condition. I, , have read and understood the above and give consent to have a gadolinium injection. I understand that despite every skill and prudent effort made to avoid complications during the examination, there is no guarantee a complication will not occur. Signature of Patient/Parent/Guardian Date Signature of Witness Rev. I 4/12100 EFTA00306882