MRI with Contrast Patient Forms

I understand that:

• The practice of medicine is not an exact science and no guarantee can be made as to the results that might be obtained from this procedure.
• Complications can occur. By consenting to this exam, I hereby consent to the necessary medical or surgical actions of the physician and/or colleagues, medical/surgical; whomever they choose to consult with to take
  appropriate actions in regard to this procedure should any complications occur during my visit.
• MedRVA Imaging may include consent at satellite offices under common ownership.

Patient Financial Responsibility

I understand my financial responsibility and I guarantee payment for all charges not covered by my insurance, all applied deductibles and co-pays, within 30 days of receiving a statement.

Medicare Patients

I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to MedRVA Imaging.

I, the undersigned, authorize MedRVA Imaging to use and disclose my information for the purposes of treatment, payment, and healthcare operations. A photocopy of this consent shall be considered as valid as the original.

 I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

1. Purpose of the Test

Your doctor has recommended that you undergo a Magnetic Resonance Imaging (MRI) scan with contrast to diagnose and/or monitor your condition. An MRI machine uses a strong magnet, radio waves, and a computer to create detailed digital images of your body.

For this test, you will receive a contrast agent that helps highlight certain tissues, blood vessels, or abnormalities. Contrast can clarify images and help your doctor better understand what is happening inside your body.

2. Description of the Procedure

The staff will prepare you for the MRI procedure by either: 1) placing an intravenous (IV) line into a vein in your arm or hand; or 2) directly injecting contrast into a joint or other specific area. Before you enter the scanner, you must remove all metal jewelry, piercings, etc. You will lie on a table that slides into the MRI scanner. You must remain still during the procedure. You may be given ear protection to soften the loud tapping and thumping sounds from the MRI machine.

3. Contraindications

MRI testing may not be considered appropriate in some circumstances (“contraindicated”). Please complete the questionnaire below to assist your care team in evaluating whether an MRI scan is appropriate for you.

If you have a pacemaker or defibrillator, you will need to go to a hospital for your procedure.

If you selected yes to any of the above surgical implants, please bring your card to the appointment.

 

Due to your medical history and/or as requested by your physician, an FDA-approved MRI gadolinium injection will be administered for this scan. To ensure that it is safe for you to receive the gadolinium contrast agent, please answer the questions below.

 

4. Risks and Side Effects

MRI with contrast is generally considered very safe. However, the MRI scan can cause injuries related to metallic objects in the body; tissue heating; heating of amniotic fluid in pregnant individuals; skin irritation, bruising, and/or swelling at the site of piercings, cosmetic implants, tattoos, and permanent makeup; and distress related to claustrophobia. Alert the MRI technologist immediately if you notice any heating or painful sensations during the scan. Failure to disclose any potential contraindications to your physician and MRI technologist could result in serious injury or even death.

Additionally, the contrast agent and its administration carry certain risks and potential side effects, including:

- Warm sensation during injection
- Cold sensation in the arm
- Headache
- Nausea
- Bruising, bleeding, pain, and/or swelling at the injection site
- Rare allergic reactions, which can cause rashes, itching, hives, trouble breathing,    and/or low blood pressure

5. Alternatives to an MRI With Contrast

Your doctor has considered the alternatives to an MRI with contrast and determined, based on your condition and risk factors, that this procedure is the most appropriate option. Alternatives to an MRI with contrast may include: 1) an MRI without contrast; 2) a CT scan (with or without contrast); 3) an ultrasound; 4) an x-ray; or 5) choosing no imaging, with the understanding it will limit diagnostic information. Your doctor can explain whether any of these alternatives are appropriate for your situation.

6. Financial Responsibility

MedRVA Imaging will bill your insurance for the procedure. However, you will be responsible for paying all charges not covered by your insurance, all applied deductibles, and co-pays within 30 days of receiving a billing statement.

7. Disclosures Related to Treatment, Payment, and Healthcare Operations

By consenting to these services, you authorize MedRVA Imaging and its affiliates to use and disclose your information for the purposes of treatment, payment, and healthcare operations.

8. Patient Acknowledgment and Consent

By signing below, you affirm the following:

I. The procedure, along with its purpose, potential risks, side effects, and alternatives, has been explained to you.

II. You understand that no guarantee can be made as to the results of the procedure.

III. You were provided an opportunity to ask questions about the procedure to your provider team.

IV. Any and all questions you have regarding the procedure have answered.

V. You understand that you may refuse or withdraw consent at any time.

VI. You have provided your physician and the MRI technologist with complete and accurate information about possible contraindications to the procedure.

VII. You understand and agree to the financial responsibility and disclosure requirements outlined above.

VIII. You consent to receiving an MRI with contrast. Additionally, in the event of complications during the procedure, you consent to the necessary medical or surgical actions of the physicians and patient care team.

I have received a Prohance Patient Medication Guide for review.