Healthcare Calcium Score Agreement

Healthcare Calcium Score Agreement

Patient Information

Date of Birth:

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Insurance Information

Medical History

Are you currently pregnant or breastfeeding? Yes No

Procedure Description and Purpose

The coronary artery calcium scoring (calcium score) is a non-invasive, electrocardiographically gated computed tomography examination performed without intravenous contrast to detect and quantify calcified plaque within the coronary arteries. The procedure involves brief exposure to ionizing radiation. The calcium score assists in estimating the burden of calcified atherosclerotic plaque and may be used with other clinical information to assess cardiac risk.

Risks, Limitations, and Alternatives

I understand the following: (a) ionizing radiation used in CT studies carries a small risk of radiation-induced effects; (b) calcium scoring does not detect non-calcified plaque and cannot rule out all coronary artery disease; (c) incidental findings unrelated to cardiac calcification may be discovered, which may require additional testing; and (d) in rare circumstances, additional imaging with contrast or alternative tests (stress testing, coronary angiography) may be recommended.

Alternatives to this examination include foregoing testing, noninvasive cardiac stress testing, or other cardiac imaging as clinically appropriate. There is no guarantee that this test will alter clinical outcome.

I acknowledge that the risks, benefits, and alternatives have been explained to me, and I have had the opportunity to ask questions and have them answered to my satisfaction.

Please initial to indicate you have read and understand the risks and limitations described above:

Authorization to Release and Financial Responsibility

I authorize release of relevant personal and medical information to my referring and treating clinicians and to my insurance carrier for purposes of treatment, payment, and healthcare operations. I understand that results will be transmitted to the ordering provider and other designated providers as authorized below.

I understand that I am financially responsible for charges associated with this examination that are not covered by my insurance, including any deductible, co-insurance, or non-covered services. I authorize assignment of benefits to the facility or provider for billing purposes and permit release of information necessary to process claims.

Authorization expires on: (If left blank, authorization will expire one year from the date of signature.)

HIPAA Acknowledgment

I acknowledge receipt of the facility’s Notice of Privacy Practices and understand that my protected health information may be used and disclosed in accordance with that notice and as necessary for my care and for billing and administrative purposes.

I authorize release of my imaging records and reports to the individual(s) named in this form or to my listed healthcare providers. I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Acknowledgment and Consent

By signing below, I voluntarily consent to have the coronary artery calcium scoring CT performed. I confirm that I have provided accurate medical history to the best of my knowledge and that I understand the nature, risks, benefits, and alternatives of the procedure. I accept financial responsibility as described above and authorize release of information as indicated.

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