Multi-Diagnostic Services, Inc.

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Multi-Diagnostic Services, Inc. 139-16 91st Avenue Jamaica, New York 11435 718 454-8556 Fax: 718 454-7950 Name: Date of Appointment: AM Time: PM What to Expect and How to Prepare for the Mammography Screening What to Expect It takes approximately 10 minutes to perform a mammography. Each breast is compressed twice. You will experience a "pinching" sensation during compression. How to Prepare 1. Wear a two-piece outfit. 2. DO NOT USE ANY POWDER, DEODORANT, LOTION OR PERFUME in the breast or armpit area. **WE WILL NOT PERFORM A SCREENING MAMMOGRAM IF YOU HAVE IMPLANTS OR HAVE STOPPED NURSING FOR LESS THAN 6 MONTHS. What to Bring Bring two envelopes: one addressed to yourself with your home address and one addressed with your ob-gyn doctor's address. These will be the envelopes we will use to mail the reports. Also, bring your completed medical history form, a copy of the front and back of your insurance card with the insurance form to your appointment. DO NOT FAX THE FORM TO OUR OFFICE. Please make every effort to obtain and bring your prior mammography films if you have not had a mammography with us in the past. They will be compared for subtle changes with your current films by our radiologist. If your mammogram results indicate a need for additional testing, you will need to bring your films with you when you have the diagnostic follow up. We will send your original films to the diagnostic center or doctor you indicate. They will be sent by either "UPS" or "Federal Express" ground, receiving signature required." Please remit S10.00 to cover the cost of the mailing. Checks can be made payable to Multi- Diagnostics and mailed to the address shown above or payment can be made by American Express, Mastercard, Visa or Discover Card. MOBILE AND ON-SITE DIAGNOSTIC SERVICES

Multi-Diagnostic Services Inc. 139-16 91st Avenue - Jamaica, NY 11435-718.454.8556 - Fax 718.454.7950 Please Print Form must be filled out completely Location of Screening Name Date of Birth / / Age Date / / Home Address Apt# City State Zip Home Telephone# ( ) Work Phone# ( ) Social Sec# PLEASE CIRCLE YOUR ANSWERS. PLEASE DO NOT LEAVE ANY UNANSWERED QUESTIONS Past/Present Medications (lf yes, state drug name and length of time used) Age you began menstruating? Birth Control Pills NO YES Number of pregnancies? Hormones NO YES Your age at first pregnancy? Thyroid NO YES Date of last period? Have you started Menopause: NO YES if yes: NATURAL SURGICAL Age Began Have you had... A hysterectomy? NO YES if yes, at what age? An Ovary Removed? NO YES (Left,Right) Age? Any Prior Breast Surgery? When? Which Breast? Radiation Treatment? Do you have any of the following NOW? Mastectomy NO YES R L Both NO YES Fibrocystic Disease NO YES Lumpectomy NO YES R L Both NO YES Breast Lumps NO YES R L Both Breast Biopsy NO YES R L Both NO YES Tenderness NO YES R L Both Drainage of Cyst NO YES R L Both NO YES Breast Pain NO YES R L Both Breast Implants NO YES R L Both NO YES Skin Retraction NO YES R L Both Other Nipple Discharge NO YES R L Both If yes, what color? Are the above symptoms related to your period? NO YES SOMETIMES Family History of Breast Cancer? (Please Circle) Previous Mammogram? Mother NO YES Aunts NO YES Mother's or Father's side? When? Sisters NO YES Grandmothers NO YES Mother's or Father's side? Where? Daughters NO YES If Yes, at what age (approximately) was the person first diagnosed? Date of last Clinical Breast Exam? OVER Technicians Signature

PLEASE READ AND SIGN ACKNOWLEDGING ITEMS 1-4 1.1 hereby give my consent and permission to Multi- Diagnostic Services. Inc., its technicians and employees, to perform a visual and/or manual breast examination and/or mammography test on me. I also understand that a visual and/or manual breast examination and/or mammography do not constitute a complete examination for cancer, nor do they guarantee the absence of cancer if the results are negative. I am solely responsible for following any recommendations made to me by the physician for any subsequent follow-up examinations, diagnostic studies, evaluations or treatments in the event that the results of the examination or mammogram are suspicious for malignancy, or there is any area of questionable abnormality found. 2.1 HEREBY DECLARE THAT TO THE BEST OF MY KNOWLEDGE I AM NOT PREGNANT AT THIS TIME AND/OR THAT I AM NOT NURSING A CHILD. 3.1 authorize Multi-Diagnostic Services, Inc. to receive any and all medical records and reports that pertain to my mammography findings. This includes, but is not limited to: ultrasound; spot, magnification, and any other additional views; biopsy results as well as previous mammography and sono films. This will enable Multi-Diagnostic Services, Inc. to update my medical chart as per Mammography Quality Standard Act (MQSA/HR6182). 4.1 understand that the results of my examination and mammography will be reported to my designated physician. If follow-up test(s) are necessary, I give my permission for Multi-Diagnostic Services, Inc. to release rny mammography films to me, a person designated by me, a doctor or the facility doing the testing. If screened through the NY State DOH Breast Health Partnership Program your films will be sent to a participating partner facility for follow-up care and your medical/personal information will be released to the corresponding NY State Partnership office and the follow-up facility listed unless you tell us not to.. Your refusal must be in writing. If desired; please provide us with the name of a relative or friend authorized to have your mammogram results along with their address and phone number: Name Address/Phone Signature Date Witness Your Physician Information Name Phone Number Address Fax Number Doctor's UPIN# (for medicare) Medicaid Provider # Medicare Patient "1 request that payment of authorized Medicare benefits be made on my behalf to Multi-Diagnostic Services. Inc. for any services furnished to me by Multi-Diagnostic Services, Inc. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Beneficiary Signature Date

Multi-Diagnostic Services, Inc. MULTI-DIAGNOSTIC INSURANCE INFORMATION SHEET JOB: 139-16 91st Avenue Jamaica, New York 11435 718 454-8556 71 8 454-7950 PLEASE PRINT CLEARLY. PATIENT NAME (AS IT APPEARS ON YOUR INSURANCE CARD) NAME OF INSURANCE CARRIER - POLICY NUMBER/ PLAN TYPE (HMO / PPO)_ HAVE YOU WAITED A YEAR SINCE YOUR LAST MAMMOGRAPHY? YES NO ARE YOU THE PRIMARY POLICY HOLDER? YES NO IF YOU CIRCLED NO ABOVE, PLEASE LIST PRIMARY POLICY HOLDER'S INFORMATION BELOW. NAME ADDRESS DATE OF BIRTH GENDER DISCLAIMER PLEASE MAKE SURE THIS IS YOUR CURRENT INSURANCE INFORMATION. PLEASE REVIEW FOR ACCURACY. WE WELL USE THIS INFORMATION TO BILL YOUR MAMMOGRAM. IF OUR CLAIM IS DENIED BY YOUR INSURANCE COMPANY FOR INCORRECT INFORMATION, YOU WILL BE RESPONSIBLE FOR THE PAYMENT OF THE MAMMOGRAPHY FEE. SIGNATURE DATE MOBILE AND ON-SITE DIAGNOSTIC SERVICES

Patient Privacy Notice Acknowledgment Form The purpose of this form is to record acknowledgment of receipt of Privacy Notice, as required by the Health Information Portability and Accountability Act of 1996 (HIPAA). Should such acknowledgment be unobtainable, this form will document the company's good faith attempt to acquire such acknowledgment. Part A: I acknowledge receipt of the University Physicians {insert patient's name) Group Privacy Notice and Practices. Signed: Date: Part B: MULTI-DI AGNOSTIC SERVICES, INCORPORATED, made a good faith attempt to obtain (insert patient's name) acknowledgment of receipt of Privacy Notice, but was unable to do so for the following rcason(s); Individual refused to sign An emergency situation prevented us from obtaining it Communications barriers prohibited obtaining it Other (please specify) Signed: Position: ; Date: (Employee) Part C: The first treatment encounter of the office with. was by {insert patient's name) telephone on, and a copy of the Notice of Privacy Practices of the office and a copy (insert date of phone call) of this Acknowledgement Form were mailed to the patient on such date, with a request to the patient to return to the office the completed Part A of this form. Signed: (Employee) Position: Date: The completed form is to be placed in the patient s medical record

INSURANCE RECEIPT Multi-Diagnostic Services, Inc. 139-16 91 Ave Jamaica. NY 11435 Tax ID# 11-2879834 PLACE OF SERVICE: Date of Service: Patient Name Patient's Address MAMMOGRAPHIC EXAMINATION CPT CODE FEE 77055 Unilateral Mammography Telephone ( )_ DOB 77056 Diagnostic Mammography 77057 Screening Mammography- Bilateral Insured's Name (if different from patients name) Insured's Address Insurance ID# 77052 CAD- Computer Aided Detection Co-Pay DIAGNOSIS ICD.9.CM (CIRCLE) 611.72 Lump or mass in breast 611.9 Unspecified disorders of breast V76.12 Breast screening, unspecified V76.11 Screening mammogram for high-risk patient Group / Plan# Total Charge: Total Paid: Balance Due:

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