Healthcare Medical Scan

HEALTHCARE MEDICAL SCAN CONSENT AND AUTHORIZATION

Patient Information

Patient Name:    Date of Birth:

Gender:    Medical Record / ID:

Phone:    Alternate Phone:

Insurance & Ordering Provider

Policy/ID Number:    Group Number:

Exam Details

Requested Exam Type: CT MRI X-ray Ultrasound PET

Medical History & Screening

Weight (lbs):    Height:

Please indicate if any of the following apply:

I am pregnant or may be pregnant Pacemaker or implanted cardiac device Metallic implants, shrapnel, or neurostimulator

Claustrophobia or anxiety in enclosed spaces Known renal impairment or dialysis Prior adverse reaction to contrast

Contrast Agent and Sedation

Use of contrast agent may be indicated to improve diagnostic accuracy. Possible risks include allergic reaction, nephrogenic systemic fibrosis with certain agents in patients with severe renal disease, and other complications.

I consent to administration of contrast agent(s) as deemed necessary by the ordering provider and radiology team.

I consent to moderate sedation if required for completion of this exam.

Risks, Benefits, and Alternatives

I understand the nature and purpose of the proposed diagnostic scan. The benefits include improved ability to detect, characterize, or monitor medical conditions. Alternatives include alternative imaging modalities or no imaging. Risks include allergic reaction to contrast, radiation exposure (CT/X-ray), heating or burns and device interference (MRI), incomplete or nondiagnostic studies, and rare but serious complications requiring emergency care.

I have had the opportunity to ask questions and understand that no guarantees have been made about the outcome of the procedure.

Authorization to Release Information & Images

I authorize release of my images and related reports to the ordering physician and other treating providers for continuity of care. I also authorize release of images and reports to the following party/entities (if applicable):

Authorization to release records and images expires on:

Financial Responsibility & Certification

I understand that I am financially responsible for charges not covered by insurance, including but not limited to facility fees, professional interpretation fees, and contrast materials. I certify that the information I have provided on this form is true and complete to the best of my knowledge.

By signing below I acknowledge that I have read and understand the above statements, that my questions have been answered, and that I consent to the indicated medical scan, administration of contrast if selected, and any necessary sedation.

HIPAA Acknowledgment

I acknowledge receipt of the facility's privacy practices and understand that my protected health information (PHI) may be used and disclosed for treatment, payment, and healthcare operations as described in that notice.

I acknowledge that I have been provided with the facility's privacy practices.

Sign Now