"*" indicates required fields 1Patient Form2Pregnancy Questionnaire And Consent Form3Medical Release Authorization Application4Health Insurance Portability and Accountability Act (HIPAA) Patient Name First Middle Last AgeDate of Birth MM slash DD slash YYYY Social Security*Gender Male Female Ethnicity/Race (Optional)Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneMobileEmail Work PhoneEmergency Contact NameRelationship to PatientPhoneReferring Doctor NameFinancial responsibilityFinancial Responsibility* Insurance Attorney Self Pay Attorney's Name*Patient Name:Insurance Name:*Subscriber Name:Date of Birth: MM slash DD slash YYYY Subscriber Social SecurityRelationship to Patient:ID number:Group number:Phone: Pregnancy Questionnaire And Consent Form Diagnostic Imaging, MRI, or X-rays, scans taken during pregnancy, may harm an unborn child. The most susceptible period for the unborn child is during the first three months of pregnancy. Severe complications may occur, including the risk of deformities and abnormalities to the child. It is important that you check one of the following statements so that Trinity Center MRI personnel are advised of your pregnancy status: The patient will be given the option to take a pregnancy test to verify status before proceeding with exam. However, if patient decides to proceed with the exam the patient releases any and all liability from Trinity Center MRI, its assigns, heirs, successors and other healthcare providers rendering services from any resultant adverse effects to any embryo or fetus due to an undiagnosed pregnancy.Patient Name First Last Date of Birth MM slash DD slash YYYY I am not pregnant. I am (or could be) pregnant at this time. Not Applicable Last Menstrual Period?I,,have been informed of the risks associated with X-ray, and MRI scans during pregnancy and all my questions have been answered. I understand that all possible shielding of my reproductive organs consistent with the examination I am receiving will be done. Having considered the benefits that may be derived from this procedure against the risks that it may impose, and having all my questions concerning the risks, benefits and alternatives answered, I have decided to have the examination. I certify that I have read and understand the above stated information and give my consent to have the examination performed, and assume any risk presented by this examination to any unborn child I am or maybe carrying. In addition, I hereby voluntarily waive all rights I may have against Trinity Center MRI with regard to this risk.I {I,:73},have been informed of the risks associated with X-ray, and MRI scans during pregnancy and all my questions have been answered. I understand that all possible shielding of my reproductive organs consistent with the examination I am receiving will be done. Having considered the benefits that may be derived from this procedure against the risks that it may impose, and having all my questions concerning the risks, benefits and alternatives answered, I have decided to have the examination. I certify that I have read and understand the above-stated information and give my consent to have the examination performed, and assume any risk presented by this examination to any unborn child I am or maybe carrying. In addition, I hereby voluntarily waive all rights I may have against Trinity Center MRI with regard to this risk.Digital Signature of Parent / Legal GuardianDate MM slash DD slash YYYY IRREVOCABLE ASSIGNMENT OF PROCEEDS AND CONVEYANCE OF LIEN INTERESTI,*Date of Birth MM slash DD slash YYYY hereby execute and provide this Irrevocable Assignment of Proceeds and Conveyance of Lien Interest in favor of TRINITY CENTER MRI This Irrevocable Assignment of Proceeds and Conveyance of Lien Interest shall apply to all monetary proceeds from any Third Party Liability Insurance Policy and/or all l monetary proceeds from any PIP/Medical Payment insurance policy to which I am entitled and from which I am to be paid in the form of an insurance settlement(s), Claim(s), or verdict(s) resulting from the above-identified accident (collectively the “insurance proceeds”). The Insurance Carrier is instructed that pursuant to this Irrevocable Assignment of Proceeds and Conveyance of Lien Interest the total dollar amount of all sums which I owe on account to the above treating facility, as evidence by the medical bills submitted by the doctor and/or treating facility, shall be paid directly to the above named treating facility by the insurance carrier out of those settlement proceeds to which I am entitled, or withheld from any settlement award to which I shall be entitled and thereafter be paid directly to the above name doctor and/or treating facility as compensation for their professional services provided to me. As consider for my execution of this Irrevocable Assignment of Proceeds and Conveyance of Lien Interest I represent that said doctor and/or treating facility has provided me professional medical services upon my request, that I am aware of the nature and expense of all such services so provided and that as consideration for my doctor’s forbearance of his/her legal right to require payment by me at the time such medical services were rendered by the said doctor and treating facility relied upon my express declaration and intention to execute and instruct that this Irrevocable Assignment of Proceeds and Conveyance of Lien Interest shall apply to all insurance proceeds to which I am or maybe entitled and direct the amount of any settlement proceeds required to satisfy my outstanding balance with the said doctor and/or treating facility at such time as I receive and insurance settlement or other monetary settlement/award. In the event my insurance settlement proceeds are paid directly to my attorney, I hereby irrevocably instruct my attorney to withhold all such sums and amounts as are determined to be owed, due, and payable on my account to such named doctor/ facility and remit payment of all such sums directly to such named doctor/ facility upon demand by the said doctor/facility. I fully understand and stipulate that I am ultimately and directly responsible to the doctor and/or treating facility for all medical bills incurred by me for those services rendered to me, or on my behalf or request and that this is agreement is made solely for the benefit of the doctor and treating facility as additional protection and in consideration of the treating facility’s agreement to forgo immediate collection of payment for such services rendered. Digital Patient or Legal Guardian Signature*Date MM slash DD slash YYYY Health Insurance Portability and Accountability Act (HIPAA)Patient Name First Last Date of Birth MM slash DD slash YYYY PRIVACY NOTICE: By Signing below; I (as patient or legal guardian of patient): Have obtained, read, and understand the Notice of Privacy Practices for Trinity Center MRI. Authorize Trinity Center MRI to contact me for appointments and administrative matters via phone, cellular, email, text, and voicemail. Understand that as a part of my healthcare record(s Trinity Center MRI originates and stores paper and/or electronic records pertaining to my health care and health history; including symptoms, examinations, results, and diagnosis. Authorize Trinity Center MRI to request/release pertinent information and copies of medical records to/from other health care providers or physicians to assure continuity of care; to/from third-party payers, review agencies, or insurance companies in order to process a reimbursement for services I receive. This includes my employer for the purposes of processing a Workman’s Compensation claim. Understand that Trinity Center MRI reserves the right to change their Notice of Privacy Practices at any time as permitted by Section 164.506 in the Code of Federal Regulations. Understand that refusal to sign this consent form may result in dismissal of care as permitted by Section 164.506 in the Code of Federal Regulations. FINANCIAL RESPONSIBILITY; By signing below; I (as patient or legal guardian of patient): Hereby assumes full responsibility for the payment of services rendered. Assign my insurance benefits, in connection with all services rendered by Trinity Center MRI; understanding that I shall be responsible for any service that is not covered in part or as a whole by my insurance. Understand that should the account be referred to collections; I shall pay all attorney fees and collection expenses. Understand that balances over (90) days are subject to a late charge of 1.5% per month (annual percentage of 18%). PATIENTS WITH MEDICARE/MEDICAID: By signing below; I (as patient or legal guardian of patient): If applicable, certify that the information I provided in applying for release under Title XVIII and/or XIX of the Social Security Act is correct. Authorize release of any information to any holder of medical/other information, the Social Security Administration, or its intermediaries or carriers. Authorize the submissions to Medicare/Medicaid for payment of authorized benefits on my behalf and assign benefits payable for diagnostic services to Trinity Center MRI MEDICAL RECORDS RELEASE: By signing below; I (as patient or legal guardian of patient): Authorize the release of any outside medical reports and/or radiologic studies to Trinity Center MRI for comparison. Authorize release of my medical record(s); inclusive of all exam results and pertinent information acquired during my radiologic examination(s) to/from other physicians and healthcare providers. Understand my right to request a copy of my medical record(s) and that I may incur fees associated with the copying of my medical record(s). Hereby authorize the release of my medical record(s) (radiologic studies and/or reports) to the following individua(s): Understand I must provide written authorization (within 24 hour notice) to release my medical record(s) to any person not listed below.Name of Authorized Individual First Last Hereby authorize the release of my medical record(s) (radiologic studies and/or reports) to the entity and/or physician listed below: Understand I must provide written authorization (within 24 hour notice) to release my medical record(s) to requesting entities and/or physicians not listed below. Name of Authorized Entity or DoctorPhone Number of Entity or DoctorPhone NumberDigital Signature of Patient or Legal GuardianDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
