Houston Medical Imaging ROUTING

Transcripción

Houston Medical Imaging
3310 Richmond Avenue
3303 Audley Street
Houston, Texas 77098
Name:___________________________ MR#:_________________________ Date:__________________________
Physician:________________________ DOB:_________________________ DOS:__________________________
ROUTING
1. __________________________ Start:_____________Stop:_____________Technician:__________________________
Time: ____________________________ Contrast:________________________Amount:________________________
Time: ____________________________
Time: ____________________________
Contrast:________________________Amount:________________________
INS INFO:_________________________
STAT:__________________
NEED FILMS:_________________
PATIENT QUESTIONAIRE
How was I treated?
Image Center Facilities
Timeliness of my exam
Overall Rating
Well Above average ____
Above Average
____
Average
____
Below Average
____
Well below average ____
Above Average
____
Average
____
Below Average
____
Above Average
____
Average
____
Below Average
____
Above Average
____
Average
____
Below Average
____
Como fue tratado?
Instalaciones del Centro
Tiempo Promedio del examen
Evaluación en general
Excelente ______
Bien
______
Regular ______
Mal
______
Muy Mal ______
Excelente ______
Bien
______
Regular ______
Mal
______
Muy Mal ______
Excelente ______
Bien
______
Regular ______
Mal
______
Muy Mal ______
Excelente
Bien
Regular
Mal
Muy Mal
______
______
______
______
______
Comments:_______________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Arrival Time:____________
Processing Complete:_____________
Initials:____________
Jacket:________________
3303 Audley Street
Name:___________________________MR#:________________ Date:____________________
Physician:________________________DOB:________________LMP:____________________
Social Security #:
____________________________
Sex:
Female ( ) Male ( )
Home Address:
____________________________
City: ________________________________
State:
_______________Zip:__________
Home Phone:
____________________________
Cellular Phone:
____________________________
Marital Status:
____________________________
E-mail Address:
____________________________
Work Phone: _________________________
Emergency Contact: ____________________________
Emergency Phone:_____________________
Guarantor Name:
Guar. Relationship:____________________
____________________________
Name of Primary Insurance:_________________________
Policy No.:_______________________
Name of Secondary Insurance:_______________________
Policy No.:_______________________
Race:
White
Hispanic
African-American
Asian
Other ____________________
I, (your name) ______________________________, authorize Houston Medical Imaging and its medical and
technical staff to perform the necessary diagnostic and treatment procedures requested by my referring doctor. I
understand that the physicians providing the services for Houston Medical Imaging are independent contractors
and are not employees of Houston Medical Imaging. I also give my authorization to Houston Medical Imaging to
release any part or all of my medical records and general information obtained during my visit to this center to
any insurance organization, my attorney and other medical personnel involved in my care or any other agency
that may require my information. I further understand that this information is stored in an electronic medical
records format and may be transmitted to my physician or authorized personnel only after proper identification
and authentication.
I authorize Houston Medical Imaging to receive direct payment from my insurance carrier or my attorney. I will
be responsible for any money deficit not covered by my insurance carrier, and I agree to make full payment of
such deficit upon receiving the balance of my medical bill from Houston Medical Imaging. I (your signature)
_______________________________ also authorize Houston Medical Imaging to release this signature to the
social security administration (Medicare) and other government agencies, Workers Compensation, or billing
agents.
Referring Physician authorizes Houston Medical Imaging (i) to contact patient’s managed care plan or other
insurer on behalf of Referring Physician to pre-certify the patient for the procedure being requested and (ii) to
provide scheduling services for the patient being referred.
3303 Audley Street
Name:___________________________MR#:________________ Date:____________________
ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY
PRACTICES OF HOUSTON MEDICAL IMAGING
By signing this document, I have received a copy of the Notice of Privacy Practices of Houston Medical Imaging
Signature
Name
Date
Office use only
Date acknowledgement received: __________________
OR
Reason acknowledgement was not obtained: _____________________________________________
FAX PRIVACY WAIVER
I understand that my medical records may be transmitted electronically by fax and may be received in
error by a third party. In the event that this should occur, I absolve Houston Medical Imaging of all
liability. I give my consent to fax my records for the purposes of treatment, payment, or healthcare options,
and I understand that I may withdraw this consent at any time in writing.
Signature of patient or representative
Printed name of patient or representative
PATIENT AUTHORIZATION FOR ACCESS TO PROTECT
HEALTH INFORMATION
I give permission for the following people to have access to my Protected Health Information and
reserve the right to revoke this at any time by notifying the office.



Any family member
Specific family member
Other (friend, caregiver)
Name(s)/Relationship
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________

I would like to have messages regarding:
My future appointment(s)
My results of test(s)
yes ___ no ____ Phone #__________________________
yes ___ no ____ Phone #__________________________
Signature __________________________ Print_____________________________ Date___________
3303 Audley Street
Name:___________________________MR#:________________ Date:____________________
Patient History
Height:____________ Weight:____________
Why did your physician order this exam?
_________________________________________________________________________________
_________________________________________________________________________________
Next appointment with your referring physician: Date _______________ Time _________________
Are you experiencing pain or other symptoms at this time? Yes ____ No ____
If yes, please describe:
_____________________________________________________________________________
_____________________________________________________________________________
Have you had any other tests or procedures performed for the same symptom(s)? Yes ____ No ____
If yes, please list exam(s) and where it (they) was (were) done: ______________________________
_________________________________________________________________________________
_________________________________________________________________________________
Do you have any history of cancer? Yes ___ No ____
If yes, please describe which part(s) of the body: _________________________________________
_________________________________________________________________________________
Are you allergic to:
Medications Yes ___ No ___ Please list: ______________________________________________
Iodine
Yes ___ No ___
______________________________________________
Do you have any kidney disorders? Yes ___ No ___ Are you currently on dialysis? Yes ___ No ___
Are you diabetic? Yes ____ No____
If yes, what medication(s) are you currently taking?
_________________________________________________________________________________
Have you had surgery in the past 5 years? Yes ___ No ___
If yes, please list all and indicate the year performed:
________________________________________________ Date ____________________________
________________________________________________ Date ____________________________
________________________________________________ Date ____________________________
________________________________________________ Date____________________________
________________________________________________ Date ____________________________
3303 Audley Street
Name:___________________________MR#:________________ Date:____________________
CONTRAST FORM / FORMA DE CONTRASTE
Test to be performed
MRI__________________
CT____________________________
Tipo de examen requerido
MRI__________________
CT____________________________
Contrast agent or pharmaceutical to be used: for an MRI OPTIMARK / for a CT OPTIRAY
Contraste o farmacéutico para ser utilizado: para MRI OPTIMARK / para CT OPTIRAY
I (name of patient)___________________________________________________give my permission to
receive the intravenous and oral examination of OPTIMARK OR OPTIRAY for the above stated
and prescribed diagnostic imaging test. I have been clearly explained of the potential risks and
complications in reference to the administration of these pharmaceutical agents and I have been told that
the reaction can range from a minimal or minor skin rash to more severe reactions that may require intense
therapy and hospitalization, and the outcome can be unpredictable.
PATIENT SIGNATURE, GUARDIAN OR PERSON LEGALLY IN CHARGE OF A MINOR OR
DISABLED PATIENT.
SIGNATURE___________________________________________ DATE__________________________
Yo (nombre del paciente) _______________________________________________ doy mi autorización
para recibir ya sea en forma oral o a través de la vena el material de contraste OPTIMARK 0
OPTIRAY requerido para la prueba de imagen a la que voy a ser sometido. Ya se me han explicado los
riesgos y las complicaciones potenciales asociadas con la administración de este material de contraste.
También se me ha explicado que las reacciones pueden ser mínimas como una urticaria o más severas que
podrían requerir terapia o hasta una hospitalización, siendo todo esto impredecible.
FIRMA DEL PACIENTE, TUTOR O PERSONA LEGALMENTE RESPONSABLE DE UN PACIENTE MENOR
O INCAPACITADO
FIRMA________________________________________________FECHA_________________________
3303 Audley Street
Name:___________________________MR#:________________ Date:____________________
Attention:
Patients using Glucophage or Glucovance
(Generic Name: Metformin)
You have undergone a radiologic procedure that involved the administration of contrast material. You are on
record as taking the medication Glucophage and/or Glucovance (generic equivalent: Metformin).
You are to discontinue the use of Glucophage/Glucovance for 48 hours after the injection of contrast.
Check with your doctor before resuming the use of this medication. A renal function test must be obtained
before resuming this medication.
Memo given on:
_____________________
Date
__________________________
Patient Signature
3303 Audley Street
Name:___________________________MR#:________________ Date:____________________
Clinical History:_________________________________________________________________
______________________________________________________________________________
PREGNANCY RELEASE FORM
Thank you for coming to our facility and allowing us the opportunity to serve you.
We sometimes ask for the cooperation of our patients by asking “personal” but
necessary and important questions in order to provide quality care.
1. Are you pregnant or do you think you may be?
Yes ___ No ___
2. Have you recently had a pregnancy test?
Yes ___ No ___
If yes, test date: ___________________ Negative ___ Positive ___
Dr. _____________________________
3. Do you have menstrual cycles?
Yes ___ No ___
If yes, please answer the following questions:
Last menstrual period start date _____________________________
4. Do you practice birth control?
Yes ___ No ___
Please indicate the method of birth control:
 Rhythm
 Tubal Ligation
 Vasectomy
 Hysterectomy
 Birth Control Pills
 IUD
 Sponges
 Condoms
 Diaphragm
 Abstinence
 Other _____________________
5. Have you been sexually active since your last menstrual period?
Yes ___ No ___
PATIENT SIGNATURE _______________________________
TECHNICAL COMMENTS: __________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Our River Oaks facility is located at:
3310 Richmond Ave. Houston, Tx 77098

Digital X-ray  Fluoroscopy  Pain Management  High-Field MRI  Mid-Field Open MRI  CT
PET/CT  Nuclear Medicine  Echovascular/Ultrasound  EKG  Ultrasound Biopsy  CT Biopsy
Our Women's Imaging facility is located at:
3303 Audley St. Houston, Tx 77098
Ultrasound  Digital Mammography  Bone Densitometry  Stereotactic Biopsy
Our Memorial facility is located at:
9180 Katy Fwy. Houston, Tx 77055
Digital X-ray  CT  High-Field MRI  Echovascular/Ultrasound  Digital Mammography
For more detailed maps and complete directions, visit http://hmixray.com/locations.php.

Houston Medical Imaging ROUTING

Transcripción

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