Colorado Heart & Body Imaging
Lung 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: ( )
-
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: __________________________
EARLY LUNG CANCER DETECTION
Please answer the following questions to the best of your knowledge:
Reason
for lung scan:
SYMPTOMS
Chest
Pain or Discomfort ð Never ð Occasionally ð Frequent ð Continuous
Shortness
of Breath (Dyspnea) ð Never ð Occasionally ð Frequent ð Continuous
Cough ð Never ð Occasionally ð Frequent ð Continuous
Coughing
up Blood (Hemoptysis) ð Never ð Occasionally ð Frequent ð Continuous
RISK FACTORS
Asbestos
Exposure ð No ð Yes
Radon
Exposure ð No ð Yes
Beryllium
Exposure ð No ð Yes
Family
history of Lung Cancer * ð No ð Yes
Exposure
to Second Hand Smoke** ð No ð Yes
Recent
Unintentional Weight Loss ð No ð Yes
*Family
history includes parents and or siblings
**Exposure
of non-smokers to environmental tobacco smoke (smoke released from a burning
cigarette and smoke exhaled from a smoker
PERTINENT PAST PULMONARY MEDICAL HISTORY
Asthma ð No ð Yes
Pulmonary
Fibrosis ð No ð Yes
Prior
Lung Cancer ( > 5 years ago) ð No ð Yes
Prior
TB History ð No ð Yes
Granulomatous Disease ð No ð Yes
Other:____________________________________________
Average
packs per day: Total years
smoked:
Average
packs per day: Total years
smoked:
Approximate
number of years since quitting:
PREVIOUS
CHEST XRAY DATE ______/______/______
Results: ÿ Normal ÿ Unavailable ÿ Abnormal suspicious for cancer ÿ Abnormal not suspicious for cancer
WOMEN ONLY
Menopause: Y
/ N Hormone Replacement: Y / N
If you are pregnant or think you might be pregnant;
you should not have the EBCT test.
PLEASE LIST ANY MEDICATIONS CURRENTLY TAKING:
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 is
likely to 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.