PATIENT INFORMATION INSURED S NAME: RELATION: PHONE #: ADJUSTORS NAME: EXT: INSURANCE CO. NAME: PHONE #: INSURED S NAME: DOB / / RELATION:
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2 PATIENT INFORMATION NAME: SS #: ADDRESS: CITY: STATE: ZIP: PHONE HOME CELL WORK BIRTH DATE: SEX: MALE / FEMALE HEIGHT: WEIGHT: MARITAL STATUS: OCCUPATION: PATIENT LIVES WITH: ALONE SPOUSE PARENTS OTHER IS THIS INJURY/ILLNESS DUE TO: A) AUTO ACCIDENT- DATE OF ACCIDENT: B) WORK INJURY- DATE OF INJURY: C) ILLNESS- DATE SYMPTOMS APPEARED: AUTO INSURANCE INFORMATION: INSURANCE COMPANY: POLICY #: CLAIM #: INSURED S NAME: RELATION: ADDRESS: CITY: STATE: ZIP CODE: PHONE #: ADJUSTORS NAME: EXT: HEALTH INSURANCE INFORMATION: DO YOU HAVE ANY TYPE OF HEALTH INS? YES or NO (circle one) INSURANCE CO. NAME: PHONE #: ADDRESS: CITY: STATE: ZIP CODE: POLICY#: GROUP: INSURED S NAME: DOB / / RELATION: ATTORNEY INFORMATION ATTORNEY S NAME: ADDRESS: PHONE: CITY: STATE: ZIP CODE:
3 INTEGRA MEDICAL IMAGING 301 North Walston Bridge Road Suite #104 Ph Fax Patient Name Patient Weight pounds Symptoms(Left/Right side) Please indicate the correct answer as it pertains to you by circling YES or NO. 1. BRAIN CLIPS (CEREBRAL ANEURYSM SURGERY) YES NO 2. CARDIAC PACEMAKER YES NO 3. PREGNANCY YES NO 4. COCHLEAR IMPLANTS (EAR SURGERY) YES NO 5. CLAUSTROPHOBIA (FEAR OF CLOSED PLACES) YES NO 6. METAL FRAGMENTS OR SHAVINGS IN HEAD, EYES YES NO OR SKIN (JOB RELATED EXAMPLE METAL WORKER) 7. AORTIC CLIPS (HEART SURGERY) YES NO 8. ARTIFICIAL HEART VALVES YES NO 9. BONES WITH RODS, PINS, PLATES OR SCREWS YES NO 10. HARRIGHNTON RODS YES NO 11. INSULIN PUMP YES NO 12. INTRAUTERINE CONTRACEPTIVE DEVICE (IUD) YES NO 13. PENILE IMPLANT YES NO 14. JOINT REPLACEMENT OR ARTIFICIAL LIMB YES NO 15. NEUROSTIM (TENS UNIT) INTERNAL/EXTERNAL YES NO 16. SHRAPNELL, GUNSHOT OR PELLET WOUND YES NO 17. SHUNT (SPINAL OR VENTRICAL) YES NO 18. WIRE SUTTURES OR METAL SURGICAL CLIPS YES NO 19. DENTURES YES NO 20. HEARING AIDS YES NO List any previous Diagnostic Test that applies to the Exam you are having today. (Example: CT Scan, Ultrasound, Bone Scan, and Prior MRI) List all previous surgeries with dates: For your safety and to obtain the best exam possible, please remove all jewelry, watches, keys, credit cards, glasses, hairpins, and dentures. You may be required to change clothes depending on which exam you are having. I have read all of the above and have been given the opportunity to ask questions concerning this exam. Patient Signature: Date: Technologist Signature: Date:
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5 ASSIGNMENT, LEIN, AND AUTHORIZATION FOR DIRECT PAYMENTS BY MY PAYERS M2-D2 LLC, dba INTEGRA MEDICAL IMAGING ( Assignment & Lien ) Purpose. The purpose of this Assignment & Lien is to assist the Office in collecting from various Payers who may be responsible for paying on my Charges. Accordingly, I agree to the following and direct all Payers as follows: Definitions. In this Assignment & Lien, the following terms shall have the following meaning: Office and Clinic shall refer to M2-D2 LLC dba Integra Medical Imaging.; located at 301 North Walston Bridge Road Suite #104, Jasper, AL Payer shall refer to without limit any insurance carrier, health benefit plan administrator and fiduciary, health maintenance organization, preferred and independent provider organization, attorney, at-fault party, individual, and any other entity, which may elect or be obligated to pay or disburse Proceeds, wither now or in the future; Proceeds shall include without limit the proceeds from any entity, which may elect or be obligated to pay or disburse Proceeds, either now or in the future; Proceeds shall include without limit the proceeds from any settlement, judgment, or verdict, the proceeds from any promise to pay or reimburse, the proceeds relating to health-care-insurance receivables and/or payment intangibles as such are defined by the applicable Uniform Commercial Code, and the proceeds relating to the following benefits, plans, or coverages: individual and group health benefits, Medicare, Medicaid, workers compensation, disability, liability, uninsured and underinsured motorist, no-fault, medical payments benefits, personal injury protection, lost wages, lost services, property damage, errors & omissions, and malpractice, Charges shall include without limit the full fees for the Office s services (including without limit treatment, diagnostic services, medical equipment, supplies, supplements, narrative reports, photoco pies, depositions, and testimony, whether rendered before or after the date of this Assignment & Lien), any Collection Costs incurred by the Office, delinquency penalties and interest to the maximum extent permitted under law or at the annual rate of eighteen percent (18%), whichever is greater, and any other charges incurred by me at the Office; : Collection Costs shall include without limit any pre- and post judgment court costs, filing fees, service of process charges, attorneys fees, fees or costs associated with requests for reconsideration, independent reviews, appeals, mediation, arbitration, and any other costs of collection incurred by the Office in any effort or action to collect my Charges either from me or from any Payer. Assignment and Lien Terms, I hereby assign to the Office to the extent permitted by law, but only to the extent of my Charges, all of my rights, remedies, and benefits relating to any Payer, including without limit a primary, non-contingent right to receive Proceeds from any Payer now or in the future, and any and all causes of action that I might have against and payer now or in the future, the right to prosecute such causes of action either in my name or in the Office s name, and the right to settle or otherwise resolve such causes of action as the Office sees fit. I agree that this assignment shall be effective as of the date and time my condition first arose. I further intend for this Assignment & Lien to create a secured interest under the applicable Uniform Commercial Code. Accordingly, I hereby grant to the Office a primary, non-primary, non-contingent secured interest in all Proceeds to the extent permitted by law for the purpose of securing payment of my Charges, which secured interest shall attach and also be automatically perfected effective as of the date and time that my condition first arose. I further authorized the Office to file the from(s) normally filed with the secretary of state or other governmental agency relating to such secured interes ts, and to make such filings in all relevant jurisdictions as the Office sees fit in its sole discretion. I agree that once payment in-full has been made towards all outstanding Charges to the full extent permitted by law or contract and also as defined by my agreement with the Office, such secured interest shall be removed or terminated solely upon my written request sent through the U.S Postal Service Certified Mail. Consistent with these terms, I hereby direct any and all Payers, to pay the Proceeds directly to, immediately to, and exclusively in the name of the Office to the full extent of my Charges. To the extent that any law, including without limit a lien statue, purports to limit through the reservation of a portion of the Proceeds exclusively to me, I hereby waive such limits, reductions, or modifications. Such waiver shall not adversely affect or prejudice any rights which the Office may have and elect to exercise under said law. Specific Direction to Any Attorney I Retain, Such as in Accident Cases. In the event that I retain one or more attorneys to assist me in the collecting any Proceeds, I hereby direct (and the Office hereby requests) each attorney to provide immediate notice to the Office regarding any Proceeds received by the attorney, to promptly pay the Office in-full out of such Proceeds, and to provide a full accounting of such Proceeds to the Office. I agree that the purpose of any Proceeds received by the attorney shall be primarily to pay my Charges. If I have a dispute regarding the Charges, any remedies I may have shall not include instructing my attorney to withhold or delay payment of Proceeds to the Office. I further agree to and hereby irrevocably waive any present or future right I may have, whether arising under a Common Fund Doctrine or other legal basis, to require the Office to reduce its Charges or balance by a proportionate or weighted share of my attorney s fees, costs and other expenses of pursuing collection of my claims, including the Office s Charges. Disclosure Directives. I hereby direct each and every Payer to immediately release to the Office any Pertinent Information relating to (a) any coverage I may have (b) any Determination by the Payer relating to the Office s Charges. Pertinent Information shall include without limit the amount of total coverage available and remaining, as well as the amount of any outstanding claims which the Payer has received from any claimant relating to my condition. Pertinent Information shall also include without limit copies of all documents, records, and other information (a) relied upon by the Payer in making a Proceeds Determination, or (b) was submitted, considered, or generated in the course of making a Proceeds Determination without regard to whether such document, record, or other information was relied upon in making the Proceeds Determination. Proceeds Determination shall include without limit any determination by the Payer to pay, deny, or delay payment of any Proceeds relating to the Office s Charges, as well as a decision to refer the Charges to an independent review or audit, utilization review, or independent medical exam. I further authorize and direct the Office to release any information relating any services rendered to or for me by the Office to all Payers, including without limit a copy of my Charges and a copy of the Assignment & Lien. Miscellaneous. Except as provided in this paragraph, this Assignment & Lien shall not be modified or revoked without the expressed, written consent of the Office. I hereby revoke, with the Office s consent, the terms of any previously signed documents, but only to the extent those terms conflict with the terms of this Assignment & Lien I agree that each and every provision of this Assignment & Lien is reasonable necessary for the protection of the rights and interests of the Office and myself. However, should any provision of this Assignment & Lien be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of this Assignment & Lien shall, nevertheless, remain in full force and effect. This Assignment & Lien shall be governed under the laws of the state where the Office is located, and is performable in the county where the Office is located. In any action ba sed upon this Assignment & Lien, I hereby consent to personal jurisdiction and venue of any court in said county and waive all objections based on improper jurisdiction, venue, or forum inconvenience. I further waive any statute of limitations which may apply in any action based upon this Assignment & Lien. I have read, understood, and agree to the terms of this Assignment & Lien. Patient Name (print): Patient Signature: Date: / / Name of Custodial Parent or Legal Guardian, on Behalf of the Patient (please print): Parent/Guardian Signature: Attorney Name (Print) Attorney Signature Date: / / Date: / /
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SHAWN A. HAYDEN, MD, PHD PATIENT PERSONAL INFORMATION. Primary Complaint Injury Date / /
SHAWN A. HAYDEN, MD, PHD PATIENT PERSONAL INFORMATION Date: / / Primary Complaint Injury Date / / Work-related: Yes No Auto Accident-related: Yes No Slip and Fall: Yes No Patient s Name: First MI Last
PRIMARY INSURANCE Subscriber s/guarantor s
For proper insurance billing. If left blank, billing will be returned for completion. PATIENT INFORMATION Name: Last Name First Name M.I. Soc.Sec.# Street Address: City: State: Zip: Phone: Other Number(s):
Welcome to Southwest Diagnostic Center!
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DEMOGRAPHICS. PATIENT INFORMATION Date Last Name First Name Middle Initial. Physical Address City State Zip. Mailing Address City State Zip
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Sex DOB Age Weight Height. Emergency Contact Phone Relationship
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REGISTRATION INFORMATION
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Patient Name: Current Smoker. Former Smoker. Do you use tobacco? qyes qno
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