UDI Mammography Intake Packet

UDI HIPAA COMPLIANCE AND RELEASE OF RECORDS (2 PARTS)
PART I. UDI HIPAA COMPLIANCE
Name

First NameLast Name (Include Maiden if Applicable)
Date of Birth

MonthDayYear
Date
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
I authorize the release of my protected health information, including records, results and images to the following person(s) (Please check all that apply and indicate names of party authorized):

SpouseChildrenOther
Name of Authorized Spouse, Child, or "Other:"
MESSAGES OR APPOINTMENT REMINDERS
Messages will be of a non-sensitive nature, such as appointment reminders.

I authorize UDI to leave messages at provided home / cell using practice name.I authorize UDI to to text or email my provided contact using practice name.DO NOT leave a message, text, or email me regarding my appointments.
PART II. OUTSIDE IMAGES/RECORDS RELEASE

(Optional)
UDI is committed to providing you and your physician quality care. If you have had relevant imaging done, please complete this portion of the form. Our Radiologists aim provide a comprehensive analysis for your condition. Please list ALL related prior Imaging Facilities.

ONLY complete the below "Prior Images/Records" portion below if applicable.
You may decline release by checking this box:

I DO NOT authorize UDI to request any outside records on my behalf.
PRIOR IMAGES RECORDS

If you would like us to obtain your outside records, please indicate where you had relevant studies done.
Name of the Center or Hospital where your prior scans were performed
Type of Films
Date of Service

MonthDayYear
If exact date is unknown, please let us know what year.
By signing this form, you consent to our use and disclosure of your protected healthcare information to only you, your doctor, your insurance and the person(s) listed below. You have the right to revoke this consent, in writing, signed by you. However, such a revocation will not be retroactive.

I have read and understand the terms of the HIPAA and Record Release sections above.
PATIENT / PARENT or LEGAL REPRESENTATIVES SIGNATURE

Clear
DATE

MonthDayYear
Date
LIFETIME AUTHORIZATION

PHYSICIAN INSURANCE ASSIGNMENT

I/we, the below named patient, insurance subscriber and/or legal representative, hereby authorize payment directly to the physician or group examining or rendering medical/surgical/anesthesia services on my behalf. I understand it is my responsibility to pay any deductibles, patient co-payment amounts, or any other balance not paid by my insurance carrier or third party payor. I agree to pay the balance due within a reasonable period of time, not to exceed 120 days . If this account is assigned to legal counsel for collection and/ or suit, the group shall be entitled to reasonably attorney’s fees and costs of collection.
Full Name
Date

MonthDayYear
Date
PATIENT / PARENT or LEGAL REPRESENTATIVES SIGNATURE

Clear
Should be Empty:

MAMMOGRAPHY SCREENING FORM

WOMEN'S UDI IMAGING CENTER

REASON FOR EXAM

BREAST SURGERY / BIOPSY

RISK ANALYSIS

PATIENT SIGNATURE:

UDI HIPAA COMPLIANCE AND RELEASE OF RECORDS (2 PARTS)

PART I. UDI HIPAA COMPLIANCE

MESSAGES OR APPOINTMENT REMINDERS

PART II. OUTSIDE IMAGES/RECORDS RELEASE

PRIOR IMAGES RECORDS