10696 S. River Front Pkwy South Jordan, UT tel fax

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1 SALT LAKE MRI, US MRI (SLMRI) S. River Front Pkwy South Jordan, UT tel fax PATIENT INFORMATION Last First Middle Initial Address City State Zip Sex Age Birth Status: SINGLE MARRIED WIDOWED DIVORCED SEPARATED Social Security # Occupation Employed By Work Employer Address City State Zip Address Cell Home RESPONSIBLE PARTY Relationship to Patient Last First Home Home Address City State Zip Social Security # Occupation Employed By Bus. Business Address City State Zip Spouse Employer INSURANCE INFORMATION Insurance Company Policyholder Birth Self Spouse Child Other Insurance Company Address Social Security # Insurance ID # Group # Medicare # 2 nd Insurance Company Policyholder Birth Self Spouse Child Other Social Security # Insurance ID # Group # AUTO ACCIDENT / WORK COMP Accident? YES NO of Accident/Injury Place of Accident: Work Auto Home School Other: Insurance Company Claim Number Adjuster Adjuster Attorney Attorney Paralegal EMERGENCY CONTACT Nearest Relative or Friend NOT Living With You Address Family Physician Referred By DIAGNOSTIC CONSENT This procedure, together with any additional or different related procedures that in the opinion of the supervising physician or radiologist may be indicated, will be performed on you by the technologist. U.S. MRI maintains personnel and facilities to assist your physician and technologist in their performance of various diagnostic procedures. These procedures may all involve risks, unsuccessful results, complications, injury, or even death from both known and unknown causes. No warranty or guarantee is made as to results. You have the right to be informed of the risks as well as the nature of the procedure, the expected benefits or effects of such procedure, and the available methods of diagnostics and their risks and benefits. Except in cases of emergency, procedures are not performed until you have had the opportunity to receive this information and have given your consent. You have the right to consent or to refuse any proposed procedure at any time prior to its performance. By signing this document, you certify that your physician and/or technologist have fully advised you of these matters. You authorize U.S. MRI to transfer you to another health care facility should the onsite physician determine it to be necessary. In addition, you also consent to the release of your medical records to such facility or other doctors, if needed. Your signature below certifies that you have read and understood the information. Provided in this form, the procedure set forth will be adequately explained to you by your technologist; you will have the chance to ask questions, be given all of the information you desire concerning the procedure, and you authorize and consent to the performance of the procedures. SIGNED DATE RELATIONSHIP

2 PATIENT SCREENING FORM : : Current weight: lbs What are your symptoms? Was this the result of an injury? If yes of injury: Was this work related? Was this from a motor vehicle accident? Please describe how you were injured: Have you had surgery on the affected area? Have you had injections in the affected area? If yes List surgeries/injections and dates below: Surgery/Injection Are you pregnant? Are there any movements or positions that make things worse? If yes, explain: WHERE IS YOUR PAIN? Locate where you are having pain on the diagram below. DRAW: (1) where you have pain (2) where you have numbness (3) where you have pain and numbness Shade where you have weakness Are you breastfeeding? Have you had any previous x-rays, CT scans, or MRI scans for this problem? If YES - When? Where?

3 PATIENT SCREENING FORM Have you felt a lump in the area we are scanning? Does your family have a history of cancer? BOX BELOW ONLY FOR THOSE HAVING CONTRAST As part of your examination, your physician may deem it necessary to give you an injection of a contrast agent containing gadolinium (contrast or dye). This injection may help in more accurately diagnosing your condition. Although gadolinium contrast agents have been used safely in millions of cases, minor reactions (principally headache, nausea, or hives) occur in about 2% of patients. HAVE YOU EVER HAD A REACTION TO GADOLINIUM CONTRAST MATERIAL? I have been informed above of any risks and/or side effects with having gadolinium contrast. I understand fully and all my questions have been answered. Patient Signature Parent/Guardian Signature MARK ALL THAT APPLY TO YOU: Neurostimulator Pacemaker Biostimulator Electronic implant device Spinal cord stimulator Insulin or infusion pump Defibulator Implanted cardioverter Implanted drug infusion device Pregnant Cardiac valve Stents Implants IUD Claustrophobic Renal insufficiency Epilepsy / history of seizures Prosthetic device Shrapnel / bullets / BB s Metal worker Dentures Hearing aid Artificial limbs or joints Aneurysm clips Tattoos Red blood cell disorder Rods, screws, plates, etc. NONE Other Patient Signature Guardian Signature

4 HIPAA AUTHORIZATION FORM Patient ID # (leave blank) This form allows the employees of US MRI to disclose the records indicated below: The following individuals are authorized to receive my protected health information: The following individual(s) are authorized to contact in case of an emergency: This authorization applies to the specific information listed below: To discuss all medical records and all billing record/ OR The authorized use or disclosure of the protected health information is for the specific purpose listed below: The authorization will expire on (date) or upon the following event: Until all medical treatment is finished and all billing issues are satisfied/ OR The use or disclose of the authorized information will result in direct or indirect compensation to USMRI from a third party. Signature of Patient / Representative Print of Patient/Representative

5 USMRI / SLMRI FINANCIAL POLICY Patient It is our office policy to inform you of our patient payment procedure. SLMRI bills insurance as a courtesy. The contract you have with your insurance is between you and your insurance carrier. That insurance contract is not between your carrier and SLMRI. If your services are provided through a Lien, you are ultimately responsible if the attorney withdraws. Please review the sections below. 1. You are responsible for deductibles, copays, noncovered services, coinsurance and items considered not a covered benefit by your insurance company. Please pay copayments and coinsurances amounts as services are rendered. Any balance unpaid after (60) days from the date of services were rendered will be considered delinquent. If you or your insurance carrier make payments exceeding your balance reimbursement will be remitted. If payment cannot be made at each visit, notify the account coordinator so that other arrangements can be made. It is the responsibility of the patient to know their insurance plan. If you have given us erroneous information, you will be responsible for the balance. 2. Workers compensation patient As a workers compensation patient, you may be covered by insurance if your injury is reported at work and verified with your employer. Be sure to inform the office personal that your injury resulted during employment. Patient is ultimately responsible for the balance. It is patient responsibility to give us correct information. 3. Personal injury (Accident) If you are a personal-injury patient, our office will bill the appropriate insurance companies. If we are unable to obtain payment, the charges for the services rendered will be your responsibility. Please give all information needed for billing at time of service. Patient is ultimately responsible for balance. 4. Medicare Our office will submit your Medicare charges to Medicare and to your secondary insurance. Patient here by agrees to be responsible for deductibles, copays, and any noncovered services. 5. Return Check Charges A return check handling charge of will be applied to all return checks. Attorney s fees and cost: If any legal action is necessary to enforce the terms of this Agreement, or if it is necessary to employ the services of an attorney, the Patient agrees to pay the reasonable attorney fees and court cost in addition to any other relief to which we may be entitled. If the patient fails to pay any amount owing hereunder when due, or otherwise breeches any terms of this agreement, patient agrees to pay the collection expense incurred by SLMRI in attempting to collect such amounts from patient, in addition to the aforementioned attorney s fees and cost. In the event any balance is not paid as agreed, the undersigned agrees to pay a collection fee not to exceed 40% of the unpaid balance. In the event of a lawsuit to collect the unpaid balance, the undersigned further agrees to pay court cost and reasonable attorney s fees in addition to the collection fee. You authorize us to call you at any number you provide or at any number at which we reasonable believe that we contact you, including calls to mobile, cellular, or similar devices for any lawful purpose. You agree to any fee or charges that you may incur for incoming calls from us, and /or outgoing calls to us, to or from any such number, without reimbursement from us. RELASE OF INFORMATION ASSIGNMENT I Assign the benefits from my insurance(s) carriers to this clinic for the medical benefits I am entitled to receive. I Authorize SLMRI to release my protective health information for treatment, payment, or operations as defined by HIPAA laws. X Patient or responsible party signature Person signing on behalf of patient (print name) Relationship to patient Witness