Healthcare Diagnostic Imaging Agreement

HEALTHCARE DIAGNOSTIC IMAGING AGREEMENT

Patient Name:    Date of Birth:    MRN:

Patient Information

Insurance and Billing

Clinical and Medical History

Requested Imaging Procedure

Type of Exam: X-ray CT MRI Ultrasound PET Other:

Scheduled Exam Date:    Scheduled Time:

Contrast and Sedation

Contrast Agent: No contrast Iodinated contrast (CT) Gadolinium-based contrast (MRI)

I acknowledge that contrast agents carry risks including allergic or idiosyncratic reactions, nephrotoxicity in patients with impaired renal function, and rare systemic effects. I have disclosed all known allergies and kidney problems.

Sedation / Anesthesia Required: Yes No

If sedation is required, I understand that there are additional risks, pre-procedure fasting instructions, and the requirement that a responsible adult accompany me home. I will follow instructions provided by clinical staff.

Consent and Authorization

By signing below I authorize the healthcare facility and its designated clinical staff to perform the diagnostic imaging procedure described above. I understand that the procedure will be performed by trained personnel and interpreted by a qualified radiologist. I have had an opportunity to ask questions regarding the benefits, risks, and alternatives to this procedure and my questions have been answered to my satisfaction.

I authorize release of imaging results and pertinent medical information to the referring physician and other treating providers as necessary for my care. I also authorize release of billing information to my insurer for claims processing.

I assign and request payment of insurance benefits to the facility to the extent permitted by my policy. I agree to be financially responsible for charges not covered or paid by my insurer, including deductibles, co-insurance, and non-covered services. I understand policies for cancellation, missed appointments, and fees, and agree to comply with facility procedures.

I understand that I may withdraw consent at any time prior to the procedure, except to the extent that action has already been taken in reliance on this authorization. Withdrawal of consent must be provided in writing to facility registration or clinical staff.

This authorization is valid for disclosure of records related to this imaging episode and expires on:

HIPAA Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices describing how protected health information may be used and disclosed. I understand my rights with respect to my protected health information and that I may request restrictions on certain uses and disclosures.

I authorize the facility to discuss my protected health information with the following persons (name and relationship):

Acknowledgments (select each to indicate understanding)

I consent to the diagnostic imaging procedure as described and understand the purpose, benefits, and risks.

If contrast is to be used, I acknowledge the risks, have reported allergies and kidney problems, and permit administration of contrast if clinically indicated.

If sedation is to be administered, I acknowledge additional risks and the requirement for escort and post-procedure instructions.

I accept financial responsibility for services provided and authorize my insurer to pay benefits to the facility where permitted.

I understand I have the right to withdraw consent prior to the procedure and that withdrawal must be provided in writing.

Cancellation and No-Show Policy

I acknowledge the facility's right to charge a cancellation or no-show fee if I fail to cancel within the timeframe required by facility policy. I agree to notify the facility promptly if I must cancel or reschedule my appointment.

Patient Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I have had the opportunity to ask questions and all questions have been answered to my satisfaction. I understand that this Agreement will be part of my medical record.

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