EFTA00283855.pdf

The Mount Sinai Hospital Name: Mount One Gustave L. Levy Place Sinai DOB: _/_/ Gender: M / F Doctors New York, New York 10029 MRN: DEPARTMENT OF RADIOLOGY MAGNETIC RESONANCE IMAGING (MRI) Location: PATIENT SCREENING QUESTIONNAIRE Physician: INSTRUCTIONS: Please answer each question below. Your responses will allow us to determine your eligibility for an MRI scan. Each box should be marked individually—please do not simply draw a line down a column. Yes No O O 1. Do you have a pacemaker, AICD, internal pacing wires, EKG leads or Hotter monitor? O O 2. Have you had brain surgery or do you have metallic clips (aneurysm clips) in your head? O D 3. Do you have an implanted stimulator (including bone growth stimulator, spinal stimulator or cochlear or other ear implant) or medication infusion pump? O O 4. Have you ever had eye surgery or implants? jp Ej 5. Have you ever worked around a metal lathe, had metal shavings or fragments in your eye(s), or had a shrapnel (war or gunshot) injury anywhere in your body? • O 6. Have any devices (e.g., stent, titter, coil or vascular port/catheter) been placed in your blood vessels? O O 5a. If you do have a stent, is it drug-eluting? O O 7. Do you have an implanted tissue expander? O O 8. Do you have a replaced heart valve, other prosthesis or any other surgical implant? O O 9. Do you have any tattoos, permanent make-up, or plercings? O O 10. Do you wear hearing aid(s), either in the ear canal or on the surface? (Remove before entering mom) O O 11. Do you wear a transdermal medication patch (e.g., Nitroglycerin, Nicotine, etc.)? O • 12. Do you have kidney/renal disease, liver disease, or diabetes? O O 13. Do you have any allergies? If so, specify: O O 14, Are you claustrophobic (afraid of enclosed or tight spaces)? O ID 16. Are you wearing a RFID or Radiofrequency ID device (commonly a wristband on an inpatient)? O ID 16. If female, are you (or could you be) pregnant or are you breastfeeding? 17. List any other type of metal in or on your body: 18. Patient age: years 19. Approximate patient weight (pounds) and patient height (feet-inches) A WARNING: Do not enter the MR system room or MR environment if you have any question or concern regarding an implant, device or object. Consult the MRI Technologist or Radiologist BEFORE entering a MR system room. The MR magnet is ALWAYS on. 20. Please o Patient a Physician print name, o Relative a Other. PRINTED NAME sign, date and time 2 /______/ SIGNATURE DATE TIME REID removed 0 Yes 0 No 0 N/A FOR DATE / / COMPLETION TIME : BY MRI MRI TECHNOLOGIST TECH SIGNATURE PERSONNEL REVIEWING DATE _/_/_ FORM TIME MRI NURSE NURSE SIGNATURE rev 8/17114 EFTA00283855  The Mount Sinai Hospital One Gustave L. Levy Place Mount Sinai New York, New York 10029 Doctors DEPARTMENT OF RADIOLOGY MAGNETIC RESONANCE IMAGING (MRI) PATIENT INFORMATION INFORMATION ABOUT SCANNING The MR scan you are to have will be performed on a state-of-the-art machine that uses a very strong magnetic field. There are no known harmful effects. The magnetization may, however, interfere with the working of a cardiac pacemaker and can move pieces of magnetized metal. Because of this, we ask you to answer all of the questions on this brief questionnaire on the reverse side of this sheet. You will be placed in a long chamber in the middle of the machine. Although the fit may seem close, the space you are in is open at both ends and the technicians are constantly in communication with you via a microphone system. If you are uncomfortable, they can hear you if you simply speak in a normal voice. You will hear a loud clicking or knocking noise sound. That is a normal function of the machine. There are no moving parts and nothing will touch or harm you. You will be given earplugs. As with regular pictures, if you move, you will ruin the images. Because of this, it is very important that you remain still and breathe normally while the scans are being taken. It is our hope to make this necessary examination as comfortable for you as possible. We will be glad to answer any questions that you may have regarding the study. PLEASE ANSWER QUESTIONS ON FRONT OF THIS SHEET, AND SIGN AT THE BOTTOM. Thank You! EFTA00283856  THE MOUNT SINAI HEALTH SYSTEM Name: Mount Sinai Mount Sinai Mount Sinai New York Mount Sinai Hospital West Beth Israel Eye and Ear Outpatient Mount Sinai Mount Sinai Mount Sinai Infirmary at Faculty Date of Birth: _/_/ Gender: Queens St. Luke's Brooklyn Mount Sinai Practices Medical Record Number (if known): RADIOLOGY OUTPATIENT Requesting Physician: ASSESSMENT QUESTIONNAIRE Today's Date: / / MEDICAL HISTORY: 1. Please indicate the reason you are having this exam (why did your doctor order this test?): 2. Please list any known diagnosis or describe any injury, pain or other symptoms related to this exam: 3a. Also, what specific part of your body is affected (location & side)? 3b. How long you have had symptoms (duration)? 3. If you have ever had cancer, Please Indicate type and year diagnosed: 4. Please list any previous surgery or treatment (including radiotherapy) related to the reason you are having this exam: 5. Have you had a nuclear medicine injection in the past 7 days, such as for bone scan or thyroid? o No D Yes Sa. If yes, what type of injection/scan, and what date did you receive it? 6. Before today, have you a No had any radiology study of the area being o Yes 4 When? examined now? What type (X-ray, ultrasound, CT, MRI, etc.)? Were prior exams at one of these Mount Sinai Health System sites? o Mount Sinai Hospital o Mount Sinai Beth Israel o Mount Sinai St. Luke's o Mount Sinai West (formerly Roosevelt) o Mount Sinai Brooklyn (formerly Kings o New York Eye & Ear Infirmary at Highway/Beth Israel Brooklyn) Mount Sinai a Another Mount Sinai-affiliated imaging center: FOR FEMALE PATIENTS OF REPRODUCTIVE AGE (11-50 YEARS): 7. To the best of your knowledge, are you pregnant or do you think you could be? O Yes O No O Possible/unsure 8. If you may be pregnant or are unsure, indicate the start of your last complete menstrual period: /_/_ FOR ALL PATIENTS, PLEASE SIGN BELOW: o Patient o Friend 9. Please print name, a Relative o other: sign, date and time PRINTED NAME 2 . SIGNATURE --/---/ THE DATE Form # RAD-1002 (Revised 10/6/2016) EFTA00283857  Icahn School of Medicine at Mount Sinai Mount Sinai Doctors Faculty Practice Financial Agreement Welcome to Mount Sinai Doctors Faculty Practice (MSDFP), a division of the Icahn School of Medicine at Mount Sinai. We are committed to providing you with the best possible care and are pleased to explain our professional fees to you at any time. Your clear understanding of our Financial Agreement is important to our professional relationship. Please ask if you have any questions about our fees, our financial policy, or your financial responsibility. PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILL ALSO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE. • REFERRALS - If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, and cannot obtain one at the time of your visit, you will be personally responsible for that day's services. • CO-PAYMENTS - By law we MUST collect your carrier's designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit. • OUT OF NETWORK PLANS - If your provider does not participate with your plan, payments for any co-insurance, deductible and non-covered amount is expected at the time of service unless prior arrangements have been made with our financial staff. We will send a courtesy bill to your insurance carrier on your behalf. Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to MSDFP for any services furnished. I understand that I am financially responsible for any amount not covered by my health insurance contract. I also authorize any holder of medical information about me to be released to my insurance company (or its agent) concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims for benefits. • SELF-PAY PATIENTS — Payment is expected at the time of service unless other financial arrangements have been made prior to your visit. • MEDICARE - We will submit claims to Medicare. You will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one. Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on my behalf to MSDFP for any services furnished to me. I authorize any holder of medical information about me to release it to the CMS (and its agents) to determine the benefits payable for related services. This information will be used for the purpose of evaluating and administering claims for benefits. • DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS — The guarantor is responsible for payment for services rendered. MSDFP cannot be involved with separation or divorce disputes. You are responsible for the timely payment of your account. Our financial staff will work closely with you and your carrier to avoid sending any account to an outside agency to collect payment. We reserve the right to send delinquent accounts to an outside collection agency. We accept CREDIT CARDS (MASTERCARD, VISA, or AMERICAN EXPRESS), CASH, or CHECKS. Our preferred method of payment is by credit or debit card. THANK YOU for taking the time to review our policies. Please feel free to ask any questions or share any special concerns you may have with a member of our staff. Patient Name: Patient Signature: Dote of Birth: Patient address: City, State: np: Today's Date: Guarantor relationship to Guarantor Signature: Guarantor Name: (if not the patient) patient: EFTA00283858 S Mount Sinai Doctors AUTHORIZATIONS AND ASSIGNMENTS 1. FINANCIAL AGREEMENT/GUARANTEE OF PAYMENT (All Patientst In Yes n No (Please initial) In consideration of services. assignment of benefits and care rendered; I agree that I am responsible for any and all charges billed by Drs. (the *Physicians" with respect to such services and care unless the contract between the Physicians and my insurance company provides otherwise. In the event that the requested services are not specifically authorized by my insurance company, I agree to pay for all services as agreed upon, unless otherwise provided by law. I authorize payment of medical benefits to which I am entitled directly to the Physicians, to cover the cost of the care and treatment rendered to myself or my dependents in the office. Upon receipt of a medical bill. I agree to immediately pay aN amounts not covered by insurance. If any insurance I have rejects my claim or pays part of the claim. I shall be responsible for payment of any balance as determined by Mount Sinai immediately upon learning of such coverage, unless otherwise provided by law. 2. RELEASE OF INFORMATION n Yes No (Please initial) In the event my insurer denies payment to the Physicians for services rendered to me. I hereby give my consent to have an authorized representative of the Physician to contact my insurer and to provide to my insurer all information and documentation regarding the services rendered to me by the Physicians which may be required in order for my insurer to reevaluate its decision to deny payment for such services. I authorize this practice, my treating physician, and their respective designees to use and disclose my health information for all necessary treatment, payment and health care operations purposes. I acknowledge that my health information may include information relating to mental illness and/or AIDS/ARC/HIV and that any such information may be disclosed (including examination and copying in either hard copy or digital format) to insurers, various credit agencies and guarantors solely if needed for payment of the professional charges (no clinical information will be disclosed to any credit agency). 3.MEDICARE-RELEASE OF INFORMATION & ASSIGNMENT OF BENEFITS (Medicare only - Part B providers) n Yes n No (Please initial) I certify that the information given by me in applying for payment under Title Will of the Social Security Act is conrect. I authorize any holder of medical or other information about me to release to the Social Security Administration and Centers for Medicare and Medicaid Services or its intermediaries or carriers any information (including information relating to mental illness and/or AIDS/ARC/HIV) needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign benefits payable to physician (8) and/or the (s) or organizations providing the service (s) 4.INSURANCE NETWORK/PROVIDER NOTICE PURSUANT TO NYS "OUT-OF-NETWORK" LAW I understand that the Physicians may be participating providers in certain health plan networks, and that a list of the plans that the Physicians participate in can be found on their website or can be provided to me upon request. I understand that the Physicians may not participate in the same health plans and networks as the hospitals and facilities in the Mount Sinai Health System even though the Physicians may be employed by or affiliated with hospitals or facilities in the Mount Sinai Health System. I understand that I can determine the health plans participated in by physicians who are employed or contracted by Mount Sinai to provide hospital services by visiting http:/hwnv.mountsinatorrgeatientcarerfind-a-doctor I also understand that I can also determine the health plans accepted by hospitals and facilities in the Mount Sinai Heath System by visiting the facility's web portal. I understand that the Physicians charge for their services separately from the hospitals and facilities in the Mount Sinai Health System. and that any bills from hospitals or facilities in the Mount Sinai Health System for so-called 'facilities" or lechnicar fees will be sent separately from the Physicians bills for their -professional services. I understand that it is my responsibility to check with the 'physician" arranging for my services regarding: (1) whether the services of any other physicians will be required fa my care; and (2) whether the services of any other physicians (including but not limited to anesthesiologists, pathologists, and/or radiologists) may be reasonably anticipated to be provided in connection with my care. I further understand that I can check with the *physician' arranging for my services to obtain the contact information and/or health plan participation information for any physicians or facility whose services may be needed in connection with my care, and that I can also contact those physicians directly to obtain information regarding their health plan participation. I HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE ITEMS. SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE DATED RELATIONSHIP TO PATIENT WITNESS TO SIGNATURE EFTA00283859