UDI MRI/CT Screening Packet

UDI

MRI and CT Screening Form (not for Mammograms or Ultrasounds)
PATIENT SCREENING FORM

MRI and CT Intake
FIRST NAME
LAST NAME
Gender

FemaleMale
Phone
D.O.B
Age
Height
Weight
Emergency Contact
ER Contact Phone Number
Reason for Exam today?
SYMPTOMS RELATED TO AN ACCIDENT?

YESNOAuto Accident?Work Related?Other?
Please list/describe symptoms you are experiencing
Female patients only:
Are you Pregnant or do you suspect that you are pregnant?

YESNOBreastfeeding?NOT Breastfeeding?
Date of last menstrual period?

MonthDayYear
Date
PREVIOUS IMAGING STUDIES

Please answer the following
Have you had previous studies to the area being scanned today?

YESNO
If YES, please indicate the date you had outside imaging done.

MonthDayYear
Date
What's the Name of the Outside Facility and the body part imaged?
CONTRAST HISTORY
Have you ever had MRI contrast (Gadolinium)?

YESNO
Did you have any kind of reaction to the MRI Contrast (Gadolinium)?

YESNO
If YES, describe the reaction that occurred:
Have you ever had CT Contrast Before?

YESNO
Did you have any kind of reaction to the CT Contrast (iodine) before?

YESNO
If YES, describe the reaction that occurred:
Are you allergic to Iodine?

YESNO
MEDICAL HISTORY
Do you have Diabetes?

YESNO
If YES, what medication(s) are you taking?
Are you on any Blood Thinners (Including daily Aspirin)?

YESNO
Do you have any Allergies?

YESNO
If YES (Allergies), please describe
Date of Last Blood work:
Facility labs were done:
Please select YES or NO for the following questions / conditions.
Sickle Cell Disease?

YESNO
Multiple Myeloma?

YESNO
Liver Disease?

YESNO
Blood Disease?

YESNO
Anemia?

YESNO
High Blood Pressure?

YESNO
Tattoos or Permanent Makeup?

YESNO
Adrenal Gland Disease?

YESNO
Cancer?

YESNO
If YES, type of Cancer and date diagnosed:
Claustrophobic?

YESNO
If YES, do you need Sedation?

YESNO
Do you smoke?

YESNO
How much?
Packs / day / week?
How long have you smoked?
Ex-Smoker?

YESNO
SURGERY HISTORY
Have you had surgery to the body part(s) being scanned today?

YESNO
If YES, please describe:
Cardiac or any type of Pacemaker?

YESNO
Implanted Cardiac Defibrillator (ICD)?

YESNO
Ear Surgery / Cochlear Implants / Hearing Aids?

YESNO
Eye Surgery / Implants / Spring Wires / Retinal Tack?

YESNO
Neuro-Stimulator / Bio-Stimulator / VNS?

YESNO
Electronic, Mechanical, Magnetic Implants?

YESNO
Brain Aneurysm Clips?

YESNO
Surgical Clips, Staples, or Wires?

YESNO
Artificial Heart Valves?

YESNO
Injury to Eye Involving Metal / Metal Shavings?

YESNO
Gunshot Wounds / Shrapnel / BB?

YESNO
Heart Surgery / Heart Valve replacement?

YESNO
Vascular Access Port / Catheter?

YESNO
Dentures or Dental Implants?

YESNO
Prosthesis: IUD, Diaphragm, Penile Implant?

YESNO
Metal Mesh Implant / Wire Sutures / Staples / Clips?

YESNO
Implanted Drug Infusion Pump / Insulin Pump?

YESNO
Titanium Plates / Pins / Screws / Rods?

YESNO
Shunts / Stents / Filters?

YESNO
Other - Not Listed Above:
PATIENT SIGNATURE
I attest that the above information is correct to the best of my knowledge. I give consent to have a contrast agent administered to me if needed for proper diagnosis of my procedure. I have read and understand the contents of this form and I have had the opportunity to ask questions regarding the information on this form.
PATIENT/PARENT/LEGAL REPRESENTATIVES SIGNATURE*

Clear
DATE*

MonthDayYear
Date
UDI

University Diagnostic Institute Winter Park, PLLC

111 North Lakemont Avenue Winter Park, FL 32792

Fax: (407)691-0316

Phone: (407)975-3315
UDI HIPAA COMPLIANCE
FIRST NAME
LAST NAME
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.
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 toonlyyou, 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): (Please check all that apply and indicate names of party authorized)

SpouseChildrenOther
If YES to Spouse, Spouse's Name:
If YES to Children, Child(ren)'s Name(s):
If YES to "Other," Other Party's Name:
MESSAGES OR APPOINTMENT REMINDERS

Messages will be of a non-sensitive nature, such as appointment reminders. Please indicate if you would like us to communicate below:
I authorize UDI to leave messages at provided home / cell using practice name.

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

DO NOT leave a message or text me.YESNO
RECORDS RELEASE FORM

USE INTENDED ONLY TO OBTAIN RELEVANT PRIORS FOR COMPARISON PURPOSES
NAME OF OUTSIDE FACILITY (NOT YOUR NAME OR UDI) Enter the Facility or Hospital where your prior scans were performed:
Type of Films (MRI, CT, MAMMOGRAM, ULTRASOUND, XRAY, And/Or BODY PART):
Enter the Date OR Timeframe of these Outside Studies (Enter "Most Recent" if unsure)
PATIENT/PARENT/LEGAL REPRESENTATIVES SIGNATURE*

Clear
DATE*

MonthDayYear
Date
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. This 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 Act is 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 thephysician, physician group or organization furnishing the services. Further I/we request the above authorization to apply to the to secondary or Medigap policy as reflected on page one.
CONTINUED RESPONSIBILITY
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 are not 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 collectionor agency collection attorney 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 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.
Print name
Date

MonthDayYear
Date
Signature*

Clear
Legal Guardian Name (if applicable)
Should be Empty:

UDI

PATIENT SCREENING FORM

PREVIOUS IMAGING STUDIES

CONTRAST HISTORY

MEDICAL HISTORY

Please select YES or NO for the following questions / conditions.

SURGERY HISTORY

PATIENT SIGNATURE

UDI HIPAA COMPLIANCE

RECORDS RELEASE FORM

ASSIGNMENT OF INSURANCE BENEFITS

CONTINUED RESPONSIBILITY