Patient Information Form

Last Name * 

First Name *  

MI  

Address *  

Apt. No.  

City *  

State *  

Zip *  

Date of Birth *  

  Under age 18?    

Social Security No.  

Phone *  

Email *  

Marital Status  
Single    Married   

Sex  
Male    Female   

Employer  

Emergency Contact *  

Contact Phone *  

Which of the following apply to this visit? *  
I have healthcare insurance   
I will self-pay   
This is a work-related injury   
This is a motor vehicle-related injury   

Benefit Agreement

I request that payment of authorized Benefits Coordination be made on my behalf to Coliseum Imaging for any services furnished me. I authorize any holder of medical information about me to release to the health care financing administration or my insurance company/agents any information needed to determine benefits payable for related services. A copy of this signature is as valid as the original. As a courtesy to you, we can file a claim to your insurance carrier/payor/attorney. Insurance Providers/Payors may deem this test medically unnecessary and there is no guarantee of benefits. By signing this form, I understand that I am financially responsible for any and all remaining balances.

Authorized Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date 

Please help us by following up with your insurance company for any unpaid claims

Notice of Intent to Protect Privacy (HIPAA)

The department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. This rule requires providers to obtain patient consent to use their healthcare information for treatment, payment or other healthcare operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We also want you to know that we support your full access to your personal medical records. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Protected Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

I hereby authorize the release of all or any portion of my medical records to any health care practitioner or facility designated by me.

Authorized Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date 

Name of person, if any, that you give permission to have access to your medical/billing records.

Name  

Relationship  

Patient Feedback Consent

Coliseum Imaging Center is committed to providing the best possible patient experience and values your feedback. By signing below you hereby authorize Coliseum Imaging Center to send you a one-time text message to rate your experience and provide an opportunity to share feedback.

Authorized Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date 

MRI Screening Form

Last name * 

First name * 

Date of birth * 

Age *  

Weight * 

Reason for MRI and/or symptoms * 

How long have you had these symptoms? * 

Are symptoms a result of a motor vehicle accident? * 
Yes    No   

Please list any surgical history by body part  

Have you had a prior medical imaging study or exam (MRI, CT, X-Ray, etc.) on the body part we are looking at today? *  
Yes    No   

Are there any medication allergies? *   
Yes    No   

Chance of pregnancy? *  
Yes    No   

Currently breastfeeding? *  
Yes    No   

Any cancer history? *  
Yes    No   

Is there any chance of metal fragments (metallic slivers, shavings, foreign body, etc.) in your eyes from welding, grinding or from an injury? *  
Yes    No   

Are you or have you been in contact with someone experiencing any clinical symptoms consistent with Coronavirus including fever, respiratory illness, including persistent coughing, shortness of breath or other flu-like symptoms? *   
Yes    No   

Please answer each of the following safety questions – do any of the following apply? *

Please list any additional information you feel is pertinent to today’s exam  

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Before entering the MRI scan room you must remove certain items from your person including:

Hearing aids, cell phone, hair pins, jewelry, watch, magnetic strip cards

Coliseum Imaging provides lockers and the MRI Technologist will direct you to one prior to your exam.