Colorado Heart & Body Imaging
Virtual
Colonoscopy
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
EBT VIRTUAL COLON SCAN QUESTIONNAIRE
Name: Age: Gender: M / F Weight:
Reason for Colon scan:
Personal history of cancer: ÿ No ÿ Yes If yes, what type?: When:
Previous abdominal or colon
surgery: ÿ No ÿ Yes If so what:
A. Tumors: ÿ No ÿ Yes Which
kind?
B. Polyps: ÿ No ÿ Yes Where?
C. Other
abnormality of abdomen or pelvis?
ÿ No ÿ Yes
Please describe:
Are you having abdominal or pelvic pain? ÿ No ÿ Yes Describe:
Do you have any family history of bowel disease? ÿ No ÿ Yes Who:
What condition?
Do you have any known colon problems? ÿ No ÿ Yes Type:
Past colon – related medical procedures: ÿ No ÿ Yes
ÿ Colonoscopy - When:
ÿ Polyp biopsy/removal - When:
ÿ Barium Enema - When:
ÿ Other: When:
Do you have a history of hemorrhoids? ÿ No ÿ Yes
Do you have rectal bleeding? ÿ No ÿ Yes
Has there been a recent change in your bowel habits or
stools? ÿ No
ÿ Yes If Yes,
How Long?
Recent unintentional weight loss or gain: ÿ No ÿ Yes
Have you seen a physician for the above conditions? ÿ No ÿ Yes
( ) -
Physician Name Physician
Phone Number
Please List Any Medications
currently taking:
Last Name: _____________________________ First Name: __________________________
I voluntarily
consent and authorize Colorado Heart Imaging physicians and technologists to
administer the testing required to perform an
Electron Beam
Tomography (EBT) Virtual Colonography Scan
Furthermore, I understand that:
ü
The primary purpose of
the colon screening is to detect early cancer or other abnormalities when the
likelihood of a cure is greater.
ü Although this is an excellent tool, it is not perfect and can miss some abnormalities including cancers at the very early stages of development and should not be considered as a substitute for or in place of a complete evaluation by a physician.
ü
I will be exposed to
radiation during the examination.
ü Since EBT is very sensitive it may identify nodules and or other abnormalities which are insignificant or not cancerous, but may require additional diagnostic tests and or procedures to evaluate the findings.
ü
Such tests and or
procedures may entail additional costs for which I am responsible.
ü
Radiology is not a
perfect science and it is possible for a radiologist to miss a significant
lesion or abnormality by this method.
ü
Colorado Heart Imaging
is not responsible for my follow – up medical care.
ü
My test results will be
made available to the physician of my choice.
ü If I develop pain, fever, chills or any other unusual symptom or symptoms related to the colon, abdomen or pelvis, I should seek medical advice.
ü
The colon will be
inflated with air, CO2 or contrast medium in order to help visualize
the colon.
ü
Oral medication to relax
the colon maybe given.
For the purpose of medical
research, I authorize Colorado Heart Imaging to accumulate and analyze data and
specimens relating to my evaluation, to obtain my previous and subsequent
medical records as needed for research purposes and to contact me for follow up
information regarding my health status in the future. This information is strictly confidential and used only for
medical research, and will not reveal my identity.
ÿ No ÿ Yes Initials:_____________
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 informed consent. I certify that I have read this form and I understand it
contents.
The report for this procedure contains medical
terminology that is likely to require interpretation by a physician.
In order to allow patients to take this test, Colorado
Heart Imaging requires that you:
ü
Identify the name
of a physician to whom we can send a copy of your medical report.
ü
Give us permission
to send a copy of the medical report for this procedure to the below named
physician.
ü
If you are a female
patient you are not pregnant.
By signing, I hereby consent that CHI may send a copy of the medical report for this procedure to my physician:
( ) -
Physician Name Physician
Phone Number
Physician
Address
City State Zip
/ /
Patient Signature Date
Last
Name: _____________________________
First Name: __________________________
In an
effort to protect your privacy, we have developed a policy for 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, P.C. 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: ( ) --
Initials
My office / work voice mail: Phone: ( ) -- Initials
My spouse: Name: Phone: ( ) -- Initials
Other: Phone: ( ) -- Initials
/ /
Patient Signature Date
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.