Healthcare Imaging Agreement

HEALTHCARE IMAGING AGREEMENT

Patient Information

Male Female Other / Prefer not to state

Insurance Information

Imaging Order and Procedure Details

Ordering Physician:

Procedure / Study Requested:

Scheduled Date:    Location / Facility:

Consent for Imaging Services

I, the undersigned patient or legal representative, hereby authorize the facility and its staff to perform the imaging procedure(s) described above. I acknowledge that the nature, purpose, expected benefits, and material risks of the procedure(s) have been explained to me and that I have had the opportunity to ask questions and receive answers.

Contrast Agent: I consent to the administration of contrast material if deemed necessary by the imaging physician. I understand that contrast agents carry risks including, but not limited to, allergic reaction, nephrotoxicity, and injection-site complications.

I consent to administration of contrast as needed

Sedation/Analgesia: If sedation or analgesia is recommended, the risks, benefits, and alternatives have been explained. I consent to administration of sedative or analgesic medication if necessary for completion of the procedure.

I consent to sedation/analgesia if required

Right to Decline: I understand that I may decline all or part of this procedure at any time prior to its performance. I further understand that refusing the recommended imaging may affect diagnosis or treatment options.

Risks, Benefits and Alternatives

Benefits: Imaging assists in diagnosis and treatment planning. Risks: Depending on the modality, risks may include radiation exposure, allergic reaction to contrast, complications from intravenous access, and potential need for repeat imaging. Alternatives: Alternatives may include other imaging modalities, conservative management, or referral to a specialist. These have been explained to me and I have had an opportunity to discuss alternatives with my provider.

Patient acknowledges discussion of risks, benefits, and alternatives

Release, Storage, and Use of Images

I authorize the release of my imaging records, reports, and images to the treating physicians, other healthcare providers involved in my care, and to the insurer for payment and utilization review. I understand that copies of images and reports may be retained in electronic or physical medical records and that they may be used for quality assurance and internal education consistent with applicable law and policy.

I authorize release and storage of images and reports for treatment and payment

I consent to de-identified use of my images for teaching, training, or research purposes (optional)

Financial Responsibility and Assignment of Benefits

I accept financial responsibility for charges associated with the imaging services provided to me. I authorize payment of benefits to the facility or provider for services rendered and assign to the provider any insurance or third-party benefits payable for these services. I understand that I remain responsible for any charges not covered by insurance, including co-payments, deductibles, and non-covered services. I agree that failure to attend a scheduled exam without timely cancellation may result in a no-show or cancellation fee.

Patient agrees to financial responsibility and assignment of benefits

HIPAA Authorization & Privacy Acknowledgment

By signing below I acknowledge that I have received or been offered the facility's Notice of Privacy Practices and that I authorize the facility to use and disclose my protected health information as necessary to provide treatment, obtain payment, and conduct healthcare operations in accordance with applicable privacy law.

Patient acknowledges receipt of privacy practices and authorizes use/disclosure of PHI

Authorization Expiration and Revocation

This authorization will expire on the date entered below or, if no date is provided, one year from the date signed. I understand that I may revoke this authorization at any time by giving written notice to the facility, but that revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of revocation.

Medical History (Relevant to Imaging)

Special Instructions / Accessibility

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