Trinity Center MRI New Patient Form "*" indicates required fields 1Patient Form2Pregnancy Questionnaire And Consent Form3Irrevocable Assignment of Proceeds4Health Insurance Portability and Accountability Act (HIPAA) Patient FormPatient Name First Last Date of Birth* MM slash DD slash YYYY 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 Emergency Contact NamePhoneFinancial responsibilityFinancial Responsibility*Date of Injury: MM slash DD slash YYYY 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 Guardian*Date 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. Digital Patient or Legal Guardian Signature*Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
