Healthcare Radiology Services Agreement

HEALTHCARE RADIOLOGY SERVICES AGREEMENT

Parties and Purpose

This Healthcare Radiology Services Agreement (the Agreement) documents the informed consent, financial authorization, and release necessary for the provision of diagnostic and interventional radiology services by the Radiology Provider to the Patient named below.

Radiology Provider Name:

Provider Address:

Patient Information

Insurance and Billing Information

Medical History and Screening

Female patients of childbearing potential: Are you pregnant or suspect you may be pregnant? Yes No

If yes or unsure, date of last menstrual period:

Procedure Details and Consent

Scheduled Procedure Date:    Scheduled Time:

I acknowledge that the Radiology Provider has explained the nature of the radiology service identified above, including the expected benefits, material risks, potential complications, and reasonable alternatives, and that I have had the opportunity to ask questions and receive answers in terms I can understand.

Contrast/Medication and Sedation Authorization

I authorize administration of intravenous or oral contrast material, sedation, and/or other medications deemed medically necessary for the performance of the procedure. I understand these agents may include iodinated contrast, gadolinium-based agents, or sedative medications, each of which carries specific risks, including but not limited to allergic reaction, injection site complications, nephrotoxicity, and, rarely, anaphylaxis.

Consent to Contrast: I consent I do not consent

Pre-Procedure Instructions

I agree to follow the provider’s pre-procedure instructions, including fasting, medication adjustments, and arrival time. Failure to comply may result in postponement or cancellation. If sedation is to be administered, I understand I must arrange for transportation home and have a responsible adult present.

Financial Responsibility and Assignment

I authorize the Radiology Provider to bill my insurance carrier and assign benefits to the provider. I understand I am responsible for all charges not covered by insurance, including co-payments, co-insurance, deductibles, and any non-covered services. If my account is referred for collection, I agree to pay reasonable collection fees and costs of collection.

Release of Records and Use of Images

I authorize the Radiology Provider to release the results, images, and related reports to the referring clinician, other treating providers, and my designated insurance carrier as necessary for treatment, payment, and health care operations. I further authorize the release of images for anonymized education, quality assurance, or peer review unless I expressly withhold such permission below.

Withhold permission for anonymized educational use: I withhold permission

Privacy and HIPAA Acknowledgment

I acknowledge receipt of the provider’s Notice of Privacy Practices describing how my health information may be used and disclosed, and I understand my rights under applicable privacy laws. I authorize use and disclosure of my protected health information by the Radiology Provider for purposes of treatment, payment, and health care operations, subject to the limitations noted herein.

Liability, Indemnity, and Dispute Resolution

The Radiology Provider will exercise reasonable care in performing services. To the extent permitted by law, the Patient agrees to release and indemnify the Radiology Provider from claims arising from the Patient’s failure to disclose relevant medical information or to follow pre-procedure instructions. Any dispute arising under this Agreement shall first be addressed through good faith negotiation; if unresolved, the parties may pursue mediation or other alternative dispute resolution before initiating litigation.

Authorization Period and Revocation

This authorization and consent remain effective for the duration of the scheduled radiology encounter and related follow-up care, unless an earlier expiration date is specified below or the authorization is revoked in writing. Revocation will not affect actions already taken in reliance on this authorization.

Authorization Expiration Date (optional):

Acknowledgment and Patient Certification

By signing below, I certify that I am the patient or the patient’s authorized representative, that I have read and understand this Agreement, that all information provided is accurate to the best of my knowledge, and that I consent to the radiology services, releases, and authorizations contained herein.

Sign Now