Memorial Mri And Diagnostic Form printable pdf download

Memorial MRI and Diagnostic

Patient’s Name: ______________________

Sex:________________________ DOB: ____________

SS# ____________________ Address: __________________________________________________

City /State/ Zip: ____________________________________________________________________

Home #: ______________________

Work #: _________________ Cell #: ___________________

Insurance Name: __________________________ ID#: ___________________

Group #: _________

Primary Card Holder if not Patient: ________________________________DOB: _________________

SS# ________________________WORKER’S COMP INFO: Employer: _________________________

Date of Injury: __________Address: ______________________ City / State/ Zip: _______________

Contact Person: ______________________ Work #: ___________________ Fax #: _____________

Attorney’s Name: _______________________

Office #: ______________ Fax #: _______________

Treatment & Insurance Authorization

Authorization for Treatment

I hereby consent to treatment by the attending physician and other medical staff for all local anesthetics, tests,

surgical and other medial procedures as deemed necessary by myself and the medical staff.

Authorization for Release of Information and Assignment of Benefits

I hereby assign to the above named office, those benefits otherwise payable to me and by any third party as

reimbursement of expenses and fees in connection with treatment rendered.

I request that payment of authorized benefits be made directly to the medical provider named above on my behalf.

I FULLY UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY AND ALL AMOUNTS NOT

OTHERWISE PAID BY MY INSURANCE CARRIER.

I certify that the information on this form given by me for payment under title XVIII (Medicare) is correct and complete. I

authorize the holder of medical or related information about me, to be released to the HealthCare Finance Administration or

other health care coverage entity, and information needed for this or any related health care claim in writing or verbally. I

further understand and agree to pay for services or amounts due when appropriate. These charges could include amounts

applied to my annual deductible co-payment amounts, and charges denied as not covered by my insurance program or deemed

medically unnecessary. I understand that well cared is not covered by Medicare or many other health insurance programs.

Date:

PATIENT SIGNATURE:

________________________________

_____________________

Medical Records Authorization

I hereby authorize the release of my films and /or medical records as needed for subsequent medical care. In the eve nt of

postive findings, I authorize my attending physician to release the results of my biopsy-surgery to the provider named above

for their records.

I hereby request that any MEDICAL RECORDS be released to:

MEMORIAL MRI & DIAGNOSTIC

1346 Campbell Road

1241 Campbell Road

Houston, Texas 77055

HOUSTON, TEXAS 77055

Office #: 713-461-3399

Fax #: 713-461-1969

Office #: 713-461-3399

Fax #: 713-461-1969

IF SOMEONE OTHER THAN THE PATIENT IS SIGNING THIS AUTHORIZATION, PLEASE STATE RELATIONSHIP WITH

PATIENT AND THE REASON PATIENT IS UNABLE TO SIGN: ____________________________________________

___________________________________________________________________________________________

Office Use Only: Information Requesting:

MRI REPORTS

MRI FILMS

ULTRASOUND REPORTS

ULTRASOUND FILMS

NUCMED FILMS

CT REPORTS

CT FILMS

X-RAYS/FLOURO REPORTS

X-

RAYS/FLOURO FILMS

Other Healthcare Information to the following treatment, condition, or date of treatment:

DATE:

PATIENT SIGNATURE

Memorial Mri And Diagnostic Form

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