UDI MAMMOGRAPHY SCREENING FORM

MAMMOGRAPHY SCREENING FORM
WOMEN'S UDI IMAGING CENTER
Name

First NameLast Name
D.O.B.
Age
Phone
Emergency Contact
Emergency Contact Phone
Where was your last Mammogram?
When was your last Mammogram?

MonthDayYear
Date
How did you find out about UDI?
REASON FOR EXAM
Type of exam being performed today?

ROUTINE SCREENINGDIAGNOSTIC
Do you have any CURRENT breast concerns?

YESNO

If YES, please indicate concern and which breast:

	LEFT	RIGHT
Lump (New or Enlarging)
Tenderness, Discomfort, or Pain
Lumpiness (Fibrocystic Changes)
Itching
Nipple Inversion
Nipple Discharge

Nipple Discharge: What Color?
Nipple Discharge: Is is Spontaneous?

YESNO
RISK ANALYSIS
Height
Weight
Has there been any significant weight change?

NOGAIN?LOSS?
Age of 1st menstrual cycle
Have you given birth to 1 or more children?

YESNO
AGE AT FIRST LIVE BIRTH
Have you gone through Menopause?

YESNO
AGE AT MENOPAUSE
Hormone Replacement Therapy (HRT) can be in the form of Medications, Supplements, Skin Patches or Injectables with Oestrogen (estradiol, estrone, and estriol - sometimes prescribed hysterectomy) and Progesterone (medroxyprogesterone - sometimes prescribed during menopause). If you have used any HRT for the conditions outlined above, the following questions are important to answer.
Have you ever taken hormones (HRT)? If YES, for how long?

Unknown1yr2yrs3yrs4yrs5yrs5+ yrs
What Type of HRT did you use?

UnknownEstrogenCombined
If NOT a CURRENT HRT user, how many years ago did you last use HRT?

Unknown1yr2yrs3yrs4yrs5yrs5+ yrs
If CURRENT HRT user, how many years do you intend to use HRT?

Unknown1yr2yrs3yrs4yrs5yrs5+ yrs
Have you ever been diagnosed with Ovarian Cancer?

YESNO
AGE AT DIAGNOSIS
Have you ever been diagnosed with ANY Cancer?

YESNO
TYPE
Have you ever been diagnosed with Congestive Heart Failure (CHF)?

YESNO
Have you had BRCA (Genetic Testing)?

YESNO
If YES, what were the results?

NormalBRCA1+BRCA2+
BREAST SURGERY / BIOPSY
Have you ever had any breast surgery?

YESNO

If YES, please indicate what type of procedure and for which breast below:

	LEFT	RIGHT
Cyst Aspiration
Needle Biopsy
Surgical Biopsy
Reduction/Lift
Lumpectomy for cancer
Mastectomy for cancer
Radiation/Chemotherapy
Breast Implants

Please describe any other symptoms you may be experiencing
Family History
FAMILY HISTORY of Breast Cancer?

YESNO
If YES, please indicate family member & AGE diagnosed below:
Members of Immediate Family
Extended Family - MATERNAL
Extended Family - PATERNAL
PATIENT SIGNATURE:
I understand mammograms do not detect all breast cancers and must be combined with periodic physical exam, monthly breast self-exam, and comparison with any prior mammograms.I understand if have developed a new breast problem, it is my responsibility to report this to my physician, and also to the technologists at the time of my mammogram.I attest that the answers - have provided on this form are correct to the best of my knowledge.
Signature

Clear
DATE

MonthDayYear
Date

I. 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. 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 authorize the release of my protected health information, including records, results and images to the following person(s):

SpouseChildrenOther
Spouse Name:
Children Name:
Other Name:
MESSAGES OR APPOINTMENT REMINDERS
I authorize UDI to leave messages at provided home / cell using practice name.

YESNO
I authorize UDI to text or email my provided contact.

YESNODO NOT leave a message or text me.
II. OUTSIDE IMAGES/RECORDS RELEASE
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.
Name of the Facility or Hospital where your prior scans were performed
Type of Films
Date of Service

MonthDayYear
Date
MAIL IMAGES TO
I have read and understand the terms of the I. HIPAA and II. Record Release (if applicable)sections above.
PATIENT/PARENT/LEGAL REPRESENTATIVES SIGNATURE

Clear
DATE

MonthDayYear
Date

LIFETIME AUTHORIZATION INSURANCE CERTIFICATE FOR PAYMENT AND ASSIGNMENT OF INSURANCE BENEFITS
I/we the below named patient, insurance subscriber and/or legal representative authorize University Diagnostic Institute Winter Park, PLLC, to bill the below-named insurance company or companies or any other insurance company required to pay benefits for the provided services to include any possible secondary insurance, automobile insurance. or workers compensation insurance for such medical services. I/we hereby assign the benefits payable from the below named insurance company or companies or any other insurance company required to pay benefits for the provided services to University Diagnostic Institute Winter Park, PLLC. assignment shall include the right for University Diagnostic Institute Winter Park, PLLC to file lawsuit on my behalf in order to collect any unpaid insurance benefits including personal protection benefits. In connection with the foregoing, I/we hereby authorize University Diagnostic Institute Winter Park, PLLC to release to the below-named insurance company or companies any information needed for collection of benefits on my/our behalf. Further I/we agree to forward any insurance payments paid to patient and/or subscriber for services rendered by University Diagnostic Institute Winter Park, PLLC. This assignment shall include the right for University Diagnostic Institute Winter Park, PLLC to obtain an unredacted copy of the personal injury protection payment log from the below named insurance company.

MEDICARE/MEDICAID CERTIFICATION FOR PAYMENT

I/we certify the information provided by me/us in applying for payment under Title XVII and/or Title XIX of the Social Security Actis correct. I/we authorize University Diagnostic Institute Winter Park, PLLC and its affiliated physicians to release to the Social Security Administration or its intermediaries or carriers any information needed for Medicare claims filed by them on my behalf. I request the payment to authorized benefits to be made on my behalf. Additionally. I/we assign benefits payable for physician services to the physician, physician group or organization furnishing the services. Further I/we request the above authorization to apply to the secondary or Medigap policy as reflected on page one.

Notwithstanding the foregoing, in consideration of services provided by University Diagnostic Institute Winter Park, PLLC to the patient named below, unless the services are covered by Medicaid, Medicare (or a Medicare Replacement product), or an HMO, or unless the applicable insurance contract provides otherwise, the undersigned is/are responsible for payment of all charges that arenot paid by the insurer or other payor. I/we understand that insurance forms will be completed by University Diagnostic Institute Winter Park, PLLC (hereinafter also referred to as "UDI") for my/our convenience. but that payment to UDI is due at the time of services are rendered. I/we also agree that if I/we have an unpaid balance and a patient refund is owed to me/us, UDI may apply the patient refund to the unpaid balance. I/we further agree that if any amount remains outstanding for a period of 120 days, that balance will be considered delinquent and turned over to a collection agency. I/we authorize the release of financially identifiable information concerning my account, including charges billed, payment made. and interest charges assessed, etc. to UDI's collection agency or collection attomey should collection procedures as described become necessary. In case of suit, I/we agree the venue shall be in Orange County. FL. I give my express permission to University Diagnostic Institute Winter Park, PLLC and its Affiliates or contractors to contact me for any purpose at the current or any future numbers that are provided for my landline telephone, cellular telephone or any wireless device including the use of automated dialing equipment, prerecorded voice, or text messages.

I/we, the below named patient and/or legal representative, hereby authorize University Diagnostic Institute Winter Park, PLLC to release any information to the Social Security Administration, its intermediaries or other government agencies, insurance carriers or legal counsel concerning diagnosis and treatment claims filed by the physician or their organization on my behalf.
PHYSICIAN INSURANCE ASSIGNMENT
I/we, the below named patient, insurance subscriber and/or legal representative, hereby authorize payment directly to the physicianor 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 paythe 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 attomey's fees and costs of collection.
Insurance Co
ID #
Type Full Name
Date

MonthDayYear
Date
Signature

Clear
Legal guardian
Should be Empty:

MAMMOGRAPHY SCREENING FORM

WOMEN'S UDI IMAGING CENTER

REASON FOR EXAM

RISK ANALYSIS

BREAST SURGERY / BIOPSY

Family History

PATIENT SIGNATURE:

I. HIPAA COMPLIANCE

MESSAGES OR APPOINTMENT REMINDERS

II. OUTSIDE IMAGES/RECORDS RELEASE

I have read and understand the terms of the I. HIPAA and II. Record Release (if applicable)sections above.

LIFETIME AUTHORIZATION INSURANCE CERTIFICATE FOR PAYMENT AND ASSIGNMENT OF INSURANCE BENEFITS

PHYSICIAN INSURANCE ASSIGNMENT