Colorado Heart & Body Imaging
Heart Scan
Date:_____/_____/_____
Last Name: First: MI: Marital Status: .
Gender: M / F Birth Date: / / Age:_____ Height: ‘ “ Weight: lbs SS#: -
- .
Mailing Address: Apt / Suite:
.
City: State: Zip: Phone: ( ) -
Physical Address (If different): City: State: Zip: .
E-Mail Address: @
Employer: Phone: ( ) -
Employer Address: Apt / Suite:
City: State: Zip: Fax: ( ) - _
Emergency Contact Name: Phone: ( )
-
Name
of referring Doctor if applicable:______________________________________
By signing this form, I am
granting consent to Colorado Heart Imaging, LLC. to use and disclose my
protected health information (PHI) for the purposes of treatment, payment and
health care operations; I also understand I will be responsible for all
non-covered services because of a lack of authorization or any other reason for
denial. Our Notice of Privacy Practices provides more detailed information
about how we may use and disclose this PHI.
You have a legal right to review our Notice of Privacy Practices before you sign this consent, and
by signing this document you fully understand the contents of our Notice of Privacy Practices.
Our Notice of Privacy Practices is subject to change at
any time without notice. If we change
our notice, you may obtain a copy of the revised notice by stopping by one of
our facilities. You have a right to
request us to restrict how we use and disclose your PHI for the purposes of
treatment, payment or health care operations.
We are not required by law to grant your request. However, if we do decide to grant your
request, we are bound by our agreement.
You have the right to revoke
this consent in writing, except to the extent we already have used or disclosed
your PHI information in reliance on your consent.
Acknowledgement of receipt
of Notice of Privacy Practices. I have been presented with a copy of
this provider’s Notice of Privacy
Practices detailing how my information may be used and disclosed as
permitted under federal and state law.
I understand the contents of the notice, and subject to the following
restriction(s) concerning my personal medical information, I agree to the
disclosures named in the notice:
Notice of Privacy Practices
/ /
Signature Date
Last Name: _____________________________ First Name: __________________________
EBT CALCIUM SCAN QUESTIONNAIRE
Please answer the following questions to the best of your knowledge:
DO YOU KNOW YOUR CHOLESTEROL
LEVEL: Y / N Date Checked:
/
/
HDL (Good) Cholesterol Amount
(If known)
LDL (Bad) Cholesterol Amount
(If known)
Triglycerides Amount (If known)
Total Cholesterol Amount (If known)
Current smoker: Y / N Number of packs: _______ per day for ________ years
Former smoker: Y / N Number of years since quitting:
High blood pressure: Y
/ N For years Latest BP / Highest BP /
Diabetes: Y
/ N Oral tablets: Y /
N Insulin: Y / N How long
on medication:___________
FAMILY
MEDICAL HISTORY
Father ð
Stroke ð
Hypertension ð Diabetes ðHeart
Disease Before 55 ð Heart Disease After 55
Brother ð
Stroke ð
Hypertension ð Diabetes ðHeart
Disease Before 55 ð Heart Disease After 55
Mother ð
Stroke ð
Hypertension ð Diabetes ðHeart
Disease Before 55 ð Heart Disease After 55
Sister ð
Stroke ð
Hypertension ð Diabetes ðHeart
Disease Before 55 ð Heart Disease After 55
EXERCISE REGULARLY: Y / N Number of days per week
ÿ < 30 MIN ÿ 30 -45 MIN ÿ 45 – 60 MIN ÿ > 60 MIN
CURRENT STRESS LEVELS: ÿ Very high ÿ High ÿ Above average ÿ Average ÿ Low ÿ N/A
CARDIAC SYMPTOMS: ÿ None
ÿ Chest pain (when / describe):
ÿ Shortness of breath (when / describe):
ÿ Chest tightness or pressure (when / describe):
ÿ Frequent palpitations (when / describe):
ÿ Syncope / fainting or near fainting (when / describe
Do you have any known
cardiovascular disease: Y / N What type
PAST CARDIAC MEDICAL
PROCEDURES: ÿ None
ÿ Bypass surgery (when):
ÿ Angioplasty (when):
ÿ Personal heart attack (when):
ÿ Stent placement (when / which vessels):
Do you have anxiety or panic
attacks causing chest pain: Y / N
PAST DIAGNOSTIC TESTS: ÿ Previous EBCT
Scan(when):________________________________
ÿ Angiogram
(when):
ÿ Thallium treadmill (Nuclear study) (when / results):
ÿ Exercise treadmill (when / results):
ÿ Stress echocardiogram (Ultrasound) (when / results):
MEDICATIONS CURRENTLY TAKING ÿ Daily Aspirin ÿ Antioxidants (vitamin C and
or vitamin E)
PLEASE LIST ANY OTHER MEDICATIONS:
Menopause: Y / N Hormone replacement: Y / N
If you are
pregnant or think you might be pregnant; you should not have the EBCT
test.
Last Name: _____________________________ First Name: __________________________
PREVENTION SCREENING DISCLOSURE AND CONSENT
I voluntarily consent and authorize
Colorado Heart Imaging physicians, technologists, and medical assistants to
administer the testing required to perform EBCT Ultrafast Cardiac screening
test.
IF YOU ARE CURRENTLY EXPERIENCING
CHEST SYMPTOMS: PAIN – SHORTNESS OF BREATH – ETC.
YOU MUST PROVIDE US WITH A PHYSICIAN’S NAME TODAY
I realize that there is a
small amount of radiation exposure associated with the EBCT procedures. I further understand that although this
screening can help identify certain early disease states, it should not be
considered a substitute or in place of a thorough examination or testing recommended
by a physician. Like all diagnostic
tests, a normal scan does not guarantee that I will not have a heart attack or
need treatment for coronary disease.
I understand that the EBCT
Ultrafast examinations are intended as screening tools and the possibility
exists that abnormalities may be found.
If such abnormalities are found, I understand that such testing and or
diagnostic procedures may be needed to further evaluate the findings. I do understand that such tests and or
procedures may entail additional costs for which I am responsible. I understand that Colorado Heart Imaging is
not responsible for my follow-up medical care.
My results will be made available to the physician of my choice.
I have been given an opportunity
to ask questions about this procedure and the risks and hazards involved and I
believe that I have sufficient information to give this informed consent. I certify that I have read this form and I
understand its contents.
/ /
Signature Date
I understand that a zero or
minimal score does not imply a zero risk of a heart attack or
coronary event.
The report for any of the
above procedures contains medical terminology that may require interpretation
by a physician.
By signing, I hereby consent
that Colorado Heart Imaging may send a copy of the medical report(s) for this
procedure(s) to my physician.
Physician Name
Physician Address
( ) -
Physician City State Zip Phone
/ /
Patient Signature Date
Last Name: _____________________________ First Name: __________________________
In an effort to protect your
privacy, we have developed a policy on leaving medical care messages.
We will NOT leave messages
with anyone except the patient or legal guardian.
We will NOT leave any information
on an answering machine / voice mail.
We have your written
permission to do so. Please read below
and consider carefully whom you want to have access to your medical
information.
I, give Colorado Heart Imaging LLC, PC my permission to leave phone
messages regarding my medical care and information as listed below. I fully understand that this authorization
will remain valid until revoked in writing.
My home / mobile answering
machine / voice mail: Phone: ( ) -
My office / work voice mail: Phone: ( ) -
My spouse: Name Phone:
( ) -
Other: Phone: ( ) -
/ /
Patient Signature Date
FINANCIAL POLICY
We are committed to providing
you with the best possible care, and are pleased to discuss our professional
fees with you at any time. Your clear
understanding of our Financial Policy is important to our professional
relationship.
We must emphasize that as
health care providers our relationship is with you, not your insurance company.
Ø
Your insurance is a
contract between you, your employer, and the insurance company.
Ø
Patients covered under a
PPO / HMO plan are responsible for complying with PPO / HMO rules, regarding
written and phone referrals from primary care physicians, if that is a
requirement of your plan.
Ø
Failure to comply with
the referral requirements of your plan will make it necessary for us to bill
you directly for charges incurred during a non-referral visit.
Ø
We will process claims
with PPO / HMO plans with which we have a contract agreement, according to that
agreement.
Ø
Required co-payments if
applicable should be made on the day services are provided.
Payment for service is
due at the time service is rendered. You are responsible for timely payment of
your account, and for any balance remaining after insurance payment has been
received. There will be a $25.00 charge
for all checks returned for insufficient funds.
I have read the above
information; I understand and agree that I am responsible for the payment of
professional services rendered.
/ /
Patient Signature Date
WELCOME TO COLORADO HEART & BODY IMAGING
Date: Name:
Please
take a moment to let us know how you heard about us!
Colorado Heart and Body Imaging invests in consumer education and awareness programs, through many different marketing avenues.
We would appreciate your time to answer the questions below.
This will enable us to focus our attention on the areas that best suits our community.
Which procedure(s) are you having done today:
(please check all that apply)
ÿ EBCT (Heartscan)
ÿ Lung
ÿ Whole Body
ÿ Virtual Colonoscopy
ÿ QCT (Bone Density)
What single event prompted you to schedule for this procedure:
Of the many different avenues of education and awareness programs that we publicize, which ONE was the most effective for you personally:
ÿ
Physician Referral Physician
Name:
ÿ Workplace: ____________________________________________________________
ÿ
Seminars / Lectures Name / Date
attended:
ÿ Internet: Site or Advertisement Name: _______________________________________
ÿ TV: Advertisement/News Story Title/Station: _________________________________
ÿ Radio: Advertisement/Station: _____________________________________________
ÿ Print (newspaper / magazine): _____________________________________________
ÿ Family / Friend: ________________________________________________________
ÿ
Other:
Your input is very important and valuable to Colorado Heart Imaging. Thank you for taking the time to help us serve our community.