Healthcare Diagnostic Imaging Amendment

HEALTHCARE DIAGNOSTIC IMAGING AMENDMENT

Patient Information

Patient Name:

Insurance and Authorization

Original Imaging Order

Ordering Physician:

Amendment Details

Amendment Request Date:

Select amendment actions (check all that apply):

Change Procedure

Add Contrast Agent / Phase

Reschedule Appointment

Change Performing Facility or Provider

Cancel Procedure

Release Images to Additional Recipient

Other (specify)

Contrast and Allergy Information

Known Allergies to Contrast or Medications:

Legal Acknowledgments and Terms

By signing below, Patient Name: authorizes this amendment which modifies the original diagnostic imaging order and consent to the extent described above. This Amendment supersedes only those terms of the original order expressly identified herein; all other terms of the original order remain in full force and effect.

Patient acknowledges that addition or modification of services (including contrast administration, additional series, extended time, or additional views) may result in additional charges for which the patient is financially responsible if not covered by insurance. Patient authorizes release of necessary information to the insurer for coverage and payment of amended services and understands pre-authorization may be required.

Patient acknowledges the facility has explained the nature and purpose of the amended procedure, reasonable alternatives, material risks (including, where applicable, contrast reactions, allergic response, and adverse events), and that no guarantees have been made regarding results. The risks described are illustrative and not exhaustive; the performing physician retains clinical discretion to alter imaging technique when necessary for safety or diagnostic yield.

This Amendment may be revoked or withdrawn by the patient in writing prior to initiation of the amended procedure; however, revocation will not affect any actions already taken in reliance on the Amendment. The facility may also decline to perform amended services if clinical assessment or insurance authorization is not satisfied.

HIPAA / Privacy Acknowledgment & Authorization Expiration

I acknowledge that I have received and reviewed the facility's privacy practices related to protected health information and that I authorize disclosure of imaging records, images, and reports to the parties reasonably necessary to carry out the amended services, billing, and treatment coordination.

Representations and Certification

I certify that the information provided on this Amendment is true and complete to the best of my knowledge. I represent that I am the patient or the legally authorized representative of the patient and that I have authority to execute this Amendment on the patient's behalf. I understand that submission of false information may subject me to civil or criminal penalties under applicable law.

Sign Now