Healthcare Diagnostic Agreement

HEALTHCARE DIAGNOSTIC AGREEMENT

This Healthcare Diagnostic Agreement (the Agreement) is entered into between the undersigned Patient and the Provider identified below. Patient Name: Date of Birth:

Provider Name: Provider Address:

1. Scope of Services

The Provider will perform diagnostic services as requested by the referring clinician or as ordered by the Provider. Services may include imaging studies, laboratory tests, physiologic monitoring, and related preparatory or ancillary procedures. Describe requested diagnostic services and/or clinical indication:

2. Consent for Diagnostic Procedures

I authorize the Provider and its authorized personnel to perform the diagnostic procedures described above, to obtain and use clinical information as necessary, and to administer routine agents or contrast materials as indicated. I understand that diagnostic procedures may include but are not limited to venipuncture, biopsy, contrast administration, radiation exposure, and other interventions required to obtain diagnostic information.

I acknowledge that the Provider has explained the nature and purpose of the procedure(s), as well as potential benefits, material risks, and reasonable alternatives. Material risks may include, as applicable: infection, bleeding, allergic reaction to contrast or medications, bruising, tissue damage, false positive or false negative results, radiation exposure, and need for additional procedures. Additional risks specific to the ordered diagnostic tests:

I have had the opportunity to ask questions and receive satisfactory answers. By checking the box below I give voluntary consent to proceed: I consent to the diagnostic procedures described above.

3. Patient Medical and Safety Information

4. Diagnostic Types and Preparations

Select the diagnostic categories included under this Agreement:

Imaging studies (X-ray, CT, MRI, Ultrasound)
Laboratory testing (blood, urine, cultures)
Pathology/biopsy analysis
Cardiac monitoring or stress testing
Other:

5. Results, Records, and Release of Information

I authorize the Provider to obtain, use and disclose my diagnostic results and related health information to the referring provider, hospitals, other treating providers, laboratories, and my health insurer as necessary for treatment, payment, and healthcare operations. I authorize release of diagnostic images, reports, and specimens as necessary for interpretation and consultation.

6. Financial Responsibility and Insurance Assignment

I understand that I am financially responsible for all charges for diagnostic services provided by the Provider that are not covered or paid by my insurance. I authorize the Provider to submit claims and to release medical information to my health plan for payment of services. If the Provider accepts assignment, payment may be made directly to the Provider.

I expressly acknowledge responsibility for co-payments, deductibles, and non-covered services. If I am financially responsible as guarantor, my billing address and contact information:

7. HIPAA Privacy Acknowledgment

I acknowledge receipt of the Provider's Notice of Privacy Practices and understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I understand my rights regarding access to and amendment of my health records and may request restrictions in writing.

I acknowledge receipt of the Provider's Notice of Privacy Practices.

8. Authorization Duration and Revocation

This authorization to perform diagnostic procedures and to disclose results will remain effective until the earlier of the completion of the diagnostic services or the expiration date stated below, unless revoked in writing. A written revocation will not affect disclosures made in reliance on this authorization prior to receipt of revocation.

9. Limitations, Liability, and Governing Provisions

The Provider will exercise reasonable professional judgment in the performance of diagnostic services. Diagnostic interpretation is inherently probabilistic; no guarantee is made as to diagnostic accuracy. To the extent permitted by law, the Provider's liability for claims arising from diagnostic services shall be limited to direct damages resulting from proven negligence. This Agreement does not waive statutory rights that may not be waived by law.

10. Emergency Treatment

In the event of an emergency arising during a diagnostic procedure, I authorize the Provider to provide or arrange for emergency medical care deemed necessary. I understand that I will be informed of such events and that additional consent may be sought as appropriate.

11. Patient Certifications

By signing below, I certify that I have read and understand this Agreement, that the information I have provided is true and complete to the best of my knowledge, and that I have had all questions answered to my satisfaction. I authorize the Provider to proceed with the diagnostic services described herein and to bill my insurance and/or me for such services in accordance with this Agreement.

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