PRIMARY INSURANCE. Subscriber Name: Subscriber ID/Policy #: Relationship to Patient: Self Wife Husband Parent Other Assignment of Insurance Benefits

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1 PATIENT INFORMATION FORM MRN: Appt Appt Time: Last Name: Social Security #: First Name: Mid. Initial: Date of Birth: Home Address: Age: Sex: Home Address 2: Home Phone #: City, State, Zip: Work Phone #: PT Cell Phone #: Referring Provider: Referring Phone #: Primary Care Physician: EMGERGENCY CONTACT INFORMATION: In case of emergency who should be notified? Name: Tel #: CONSENT TO RELEASE PROTECTED HEALTH INFORMATION (PHI) TO THE FOLLOWING PERSON(S): Name: Relationship: Name: Relationship: Name: Relationship: PRIMARY INSURANCE Plan Name: Group #: Plan Tel #: Subscriber DOB: Subscriber Name: Subscriber ID/Policy #: Relationship to Patient: Self Wife Husband Parent Other SECONDARY INSURANCE Plan Name: Group #: Plan Tel #: Subscriber DOB: Subscriber Name: Subscriber ID/Policy #: Relationship to Patient: Self Wife Husband Parent Other Assignment of Insurance Benefits I authorize payment of medical benefits to: Mammography and Ultrasound Imaging Center, PLLC for services rendered. I also authorize the release of any medical information necessary to process my insurance claims. I request and authorize that payment/insurance benefits be made directly to Mammography and Ultrasound Imaging Center, PLLC any services furnished to the above named patient by Mammography and Ultrasound Imaging Center, PLLC. The signature below shall suffice for all insurance forms on a continuing basis. I agree to pay Mammography and Ultrasound Imaging Center, PLLC for all charges for services not covered by Insurance Payer. Patient or authorized person s signature:

2 BREAST QUESTIONNAIRE MRN: Appt Appt Time: Patient Name: Date of Birth: Age: «PatientAge» Sex: «PatientSex» Age of First Menstrual Period: Menopause Age: NATURAL SURGICAL NEW lumps in breast? NO YES RIGHT LEFT NEW pain or discomfort? NO YES RIGHT LEFT NEW discharge from nipple? NO YES RIGHT LEFT Do you have breast implants? NO YES SALINE SILICONE Any previous breast surgeries? NO YES RIGHT LEFT If yes, age: Type of surgery: Results: Are you taking Estrogen? NO YES FAMILY history of BREAST cancer? NO YES If yes, relationships? Maternal Paternal Personal history of BREAST cancer NO YES Have YOU had a personal history of OTHER types of cancer? NO YES If yes, what type? Have you had a mammogram before? NO YES If yes, what facility? When? To the best of my knowledge the above information is correct. Signature: CONTINUED ON PAGE 2

3 Digital Screening Mammograms I understand that if additional views are required for complete diagnosis; a Digital DIAGNOSTIC mammogram may be billed in addition to the Digital SCREENING mammogram. Additionally if a breast ultrasound is performed it may be added and will be reflected in the charges. Patient s Signature: Medicare Limitation of Liability Medicare will only pay for services it determines to be reasonable and necessary under Section 1862(A)(1) of the Medicare law. If Medicare determines that a particular service is NOT reasonable and necessary under Medicare program standards, Medicare may deny payment for the following reason: Under Medicare rules, screening mammograms are allowed and payable once every 12 months for women age 40 and over. For women under age 40, Medicare allows one screening mammogram every 24 months. PROCEDURE CODE CHARGE POSSIBLE REASON FOR DENIAL G0202 (Screening) $ See above (CAD) $ See above Patient s Signature: PAGE 2

4 3D TOMOSYNTHESIS BREAST WAIVER Date of Service: Patient Name: MRN: Date of Birth: Age: Sex: We are pleased to announce that MUSIC is now providing 3-D tomosynthesis mammography to our patients. Tomosynthesis is a revolutionary 3-D technology which uses x-rays like the standard digital 2-D mammography. The x-ray tube moves like an arc over the breast taking pictures at different angles of the breast. These multiple projections of the breast create a layer-by-layer view of the breast thus removing tissue overlap that may hide cancers. 3-D mammography allows the radiologist to view the breast in greater detail and this imaging has been shown to increase the detection of invasive cancers by over 40%. Breast tomosynthesis is used in conjunction with standard 2-D digital mammography as a part of the screening or diagnostic examination. Presently the dose is equivalent to the standard digital mammogram. From the patient s perspective the equipment appears identical and the procedure is very similar as the experience with the standard mammography. Interpretation of images will take longer by the radiologist so your wait time may be increased. Presently only three insurance carriers reimburse for this new technology-medicare, AvMed and Humana. Other insurance carriers will not pay for digital breast tomography since this test does not meet the payment determination criteria. It is important that each patient make an informed choice whether to receive this new service. If you chose this service an additional charge will be assessed. Your insurance carrier will be billed as normal for the standard 2-D digital mammogram. We hope in the near future that other insurance carriers will pay for this service. Beneficiary Agreement I have been notified by my provider that my insurance carrier will not pay for the breast tomosynthesis that I am requesting. I agree to be personally and fully responsible for the payment of the service, for which the provider s charge is $ I accept these services. Patient s Signature: Witness Signature: I decline these services at this time. Release of Records Authorization

5 Consent to use, obtain, and disclose protected health information Patient Name: DOB: PHONE: I, «PatientFullName», hereby give my permission to Mammography and Ultrasound Imaging Center, PLLC to obtain my protected health information from others for the purpose of treatment, obtaining payment, or supporting the day-to-day operations of the practice. I hereby give my permission to Mammography and Ultrasound Imaging Center, PLLC to use and disclose my protected health information disclosed by another covered entity for the purposes of treatment, obtaining payment, or supporting the day-to-day operations of the practice. This release covers all my personal health information including but not limited to medical reports, progress notes, CDs, films, diagnostic studies, lab work, and any other documentation requested by Mammography and Ultrasound Imaging Center, PLLC for the purposes of treatment, obtaining payment, or supporting the day-today operations of the practice. I understand that Mammography and Ultrasound Imaging Center, PLLC may request this information from health care providers, hospitals, ancillary service providers, and other entities. I understand that Mammography and Ultrasound Imaging Center, PLLC will use my personal health information solely for the purposes of treatment, obtaining payment, and supporting the day-today operations of the practice. A copy of this release is as valid as the original. This is a lifetime release unless revoked by me in writing. Facility Name: Facility City/State: Type of records: Mammography/Ultrasounds/Bone Density-Imaging and Report Other records (be specific): Name of Person Signing Below (PRINT): Relationship to Patient: Signature of Patient or Parent/Guardian:

6 CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS, AND CONSENT TO PERFORM SERVICES ORDERED I, «PatientFullName» understand that as part of my health care, Mammography & Ultrasound Imaging Center, PLLC originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment; A means of communication among the many health professionals who contribute to my care; A source of information for applying my diagnosis and surgical information to my bill; A means by which a third-party payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: The right to review the notice prior to signing this consent; The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. I understand that Mammography & Ultrasound Imaging Center, PLLC is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. I further understand that Mammography & Ultrasound Imaging Center, PLLC reserves the right to change their notice and practices and prior to implementation, in accordance with Section of the Code of Federal Regulations. Should Mammography & Ultrasound Imaging Center, PLLC change their notice, they will send a copy of any revised notice to the address I ve provided (whether U.S. mail or, if I agree, ). I wish to have the following restrictions to the use or disclosure of my health information: I understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I UNDERSTAND THAT BY SIGNING THIS FORM I AM CONSENTING TO THE SERVICES ORDERED I fully understand and accept / decline the terms of this consent. (Circle one) Patient s Signature: FOR OFFICE USE ONLY MRN: [ ] Consent received by on [ ] Consent refused by patient, and treatment refused as permitted. [ ] Consent added to the patient s medical record on

7 Today s MRN: Patient Name: Sex: M F NO CHANGES FROM PRIOR VISIT RACE DECLINE TO ANSWER Caucasian/White Black/African American Asian Native America Asian Pacific American Pacific Islander Subcontinent Asian American American Indian/Native Alaskan Native Hawaiian Other Race Decline to Answer Do not know ETHNICITY Latino/Hispanic Non-Latino Hispanic Decline to answer PREFERRED LANGUAGE English Other: (Please Specify) TOBACCO HISTORY Do you currently Smoke? YES NO If No, Have you ever Smoked? YES NO If YES, do you smoke daily? YES NO Do you currently use smokeless tobacco? YES NO Have you ever used smokeless tobacco? YES NO MEDICATION HISTORY ALLERGIES No Known Allergies NOT CURRENTLY ON ANY MEDICATIONS CURRENT MEDICATION LIST Patient Signature: Reviewed By:

8 Directions to our Office 7550 W University Ave, Suite A, Gainesville, Fl From Newberry Rd/State Rd 26: 1. Turn onto NW 75 th St (Tower Rd) and proceed 0.4 miles 2. Turn right onto W University Ave 3. Take the third right and your destination will be on the left From SW Archer Rd: 1. Turn onto SW 75 th St (Tower Rd) and proceed 3.8 miles 2. Turn left onto W University Ave 3. Take the third right and your destination will be on the left. If you have any questions about our location please feel free to call us at (352) We will be happy to assist you.

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