8149 Kennedy Ave Suite A, Highland, Indiana 46322

Timing: Mon- Sat: 8am-6pm
[email protected]
(219) 923-8540

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About Us
Services
- MRI
- CT Scan
- Ultrasound
- X-Ray
FAQs
Book Appointment
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Contact Us

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Patient Demographics

Home > Patient Demographics

Name *

First VisitYesNo

Email Address *

How did you hear about us?

FriendDoctorOnlineOther

Social Security # *

D.O.B *

Sex *MF

Marital Status *SMDW

Street Address *

City/State/Zip *

Home Phone *

Cell *

Work

Employer

Address

Occupation

Full TimePart TimeStudent

Emergency Contact Name *

Relationship

Phone *

Referring Physician

Primary Physician

Who will be responsible for your account? *SelfInsuranceSpouseFatherMotherOther

Insurance Company Name

Phone number

Insurance policy number

Insurance Plan

Group

Name

SSN

Phone

Address

City/St/Zip

Employer

Phone

Work RelatedYesNo

Is an Attorney Involved?YesNo

Auto AccidentYesNo

Attorney Name

Phone

Injury Date

Claim #

Have you ever had an MRI scan of the body area we are going to scan today?YesNo

History of Cancer?YesNo

If yes, what type

Recent SurgeryYesNo

If yes, what type

Have you ever done metal work such as cutting, welding, or using a grinder?YesNo

If YES, have you ever had metal fragments lodged in your eyes?YesNo

Have you ever had any heart surgery?YesNo

If YES, do you have a Pacemaker, stent or Artificial Heart Valve?YesNo

Have you ever had any head surgery?YesNo

If YES, do you have any clips, such as aneurysm clips, and if so, what year were they inserted?

If YES, what type and when was the surgery performed?

Have you ever had any surgeries to do with the body part being scanned?YesNo

If YES, what type and when was the surgery performed?

Do you have any implanted metal in your body (i.e. due to surgery, shrapnel, bullets, etc.)?YesNo

Do you have any dental implants, bridgework, or dental plates that are removable?YesNo

Do you have any artificial or prosthetic limbs?YesNo

Do you have any other implants, pins, mesh, wires, pumps or device?YesNo

If YES, what type?

Do you have a hearing aid or an ear implant?YesNo

Do you have any permanent tattoos or permanent makeup?YesNo

Are you claustrophobic (fear of being in small, confined places)?YesNo

Do you have any other medical conditions? Please list:

All jewelry, hairpins, electrodes and wigs must be removed prior to entering the MRI scan room.Agree

Consent to Treat: I request and give consent to Saint Mary Open MRI & CT to provide and perform such medical/surgical care, tests, procedures, drugs, and other services and supplies as are considered necessary or beneficial by my physician for my health and well being. I acknowledge that no representations, warranties, or guarantees as to the results or cures have been made to me or relied upon me.Agree

Release of Medical Information and Authorization to Pay Insurance Benefits: I authorize Saint Mary Open MRI & CT to release information from my medical record to my insurance carrier(s), or government agency for the processing of claims for medical benefits. I request that my insurance company(s) honor my assignment of insurance benefits applicable to the services and pay all assigned benefits directly to Saint Mary Open MRI & CT on my behalf.Agree

Medicare Certification: I certify that the information given by me in applying for payment under the Title XVIII of the Social Security Act is correct. I authorize Saint Mary Open MRI & CT who treats me, to release information from my medical record to Social Security Administration and or the Medicare Program or its intermediaries or carriers, or to the Professional Standards Review Organization for the processing of claims for medical benefits. I request that payment of authorization of benefits be made directly to Saint Mary Open MRI & CT treating me, on my behalfAgree

Financial Agreement: I understand all accounts are full responsibility of the patient and/or the patient’s responsible party/guarantor. It is the patient responsibility to make sure insurance payments are processed and paid promptly to Saint Mary Open MRI & CT. In the case of default, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorneys fees incurred to effect collection of this account or future outstanding accounts.Agree

I understand, verify that all the answers I have are true to the best of my knowledge. I give Saint Mary Open MRI & CT permission to perform the examination(s) requested by Saint Mary Open MRI & CT. I authorize for Saint Mary Open MRI & CT to disclose information regarding appointments, preps, and billing information on my answering machine or voicemail. I authorize the release of any medical information necessary to process this claim. I understand that I am responsible for all co-payments, coinsurance, and services deemed “non-covered” by my insurance company. I also authorize payment of medical benefits to Saint Mary Open MRI & CT for services rendered. I have read the above and fully understand its content. In the event the insurance company remits funds to me, it is my responsibility to remit directly to Saint Mary Open MRI & CT.Agree

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your medical information is important to us. As a medical health care facility we use and transmit information regarding you and your medical condition and the tests we perform. We need to use this information in many ways. First, we use the information for your (treatment) to create a record of the care and services you received at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. Your protected health information (PHI) may be used and disclosed by our radiologists, technologists, nurses, office staff, billing staff, and others outside of our office that are involved in completing your diagnostic test for the purpose of providing health care services to you. Secondly, we use this information about you to(process payment) for the medical care you received. Thirdly, we use this information for your (healthcare operations). Your PHI may be used or disclosed as a part of our internal health care operations. Such health care operations may include: quality of care audits, training programs, accreditations, certifications, licensing or credentialing activities. We understand this information is personal and private and we are committed to protecting your medical information. Under the Health Insurance Portability and Accountability Act (HIPAA) each patient has certain rights to the medical information kept at this facility. Certain restrictions may apply. These rights are: Access. You can request a copy of your health care information. You also have the right to review or to purchase copies of your PHI by requesting access or copies in writing to our Privacy Officer. Please note a fee will be assessed. Restriction. You have the right to request a restriction or limitation on our use or disclosure of your PHI. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request. If we agree to such restrictions we will do so in writing signed by our Privacy Officer. We are not required to agree to a restriction that you may request. If we believe is in your best interest to permit use and disclosure of your protected health information, your health information will not be restricted. You have the right to use another health care facility if you do not agree.Agree

Alternative Communication. You have the right to request that we communicate with you about your protected health information by alternative means or in alternative locations such as a specified phone number or mailing address. We will accommodate any reasonable request if you would like to receive an accounting of certain disclosures we have made, if any, in which your PHI was disclosed for purposes other than those described in the following sections. For each 12 month period you have the right to receive one free copy of an accounting of certain details surrounding such disclosures that occurred after July 15, 2006.Amending. You have the right to request that we amend your protected health information if you feel it is wrong. Any such request must be in writing. We have the right to deny your request for amendment, and will give you a written explanation of the denial. You have the right and can file a statement of disagreement with us and we will prepare a written rebuttal to your request. Complaints. You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us in writing and a response will be forwarded to you within 30 days. This notice was published and becomes effective on/or before July 15,2006.Disasters. We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in disaster relief efforts. Required by Law. We may use or disclose your PHI when we are required to do so by law. For example, your PHI may be released when required by privacy laws, workers compensation or similar laws, coroners, medical examiners, funeral directors, health directors, health oversight agencies or government programs or their contractors, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please speak with our HIPAA compliance officer in person. Signature below is acknowledgment that you have received this notice of our privacy practices and agree to treatment at our facility under our current policy.Agree

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8149 Kennedy Ave Suite A, Highland, Indiana
[email protected]
(219) 923-8540

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