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Consent for Diagnostic Imaging Services

Preferred Family Medicine Consent Form for Diagnostic Imaging Services

Consent Form for Diagnostic Imaging Services - Ultrasound

PREFERRED FAMILY MEDICINE

9120 DOUBLE DIAMOND PKWY RENO, NV 89521 (775) 204-1050

1. Cash-Pay Acknowledgment

I understand that Preferred Family Medicine operates on a cash-pay basis for ultrasound and diagnostic imaging services and does not bill insurance, including Medicare or Medicaid. I am responsible for full payment at the time of service.

2. Electronic Communication Consent

I consent to receive and discuss my diagnostic imaging results electronically with Preferred Family Medicine and NV Premier Ultrasound. I understand the inherent risks and accept that absolute security cannot be guaranteed.

3. PHI Sharing Authorization

I authorize Preferred Family Medicine to share my Personal Health Information with referring providers or designated entities as listed below for seamless care coordination: Referring Provider/Entity Name:

4. Credit Card Authorization

If paying by credit card, I authorize Preferred Family Medicine to charge my credit card for payment of diagnostic imaging services rendered. I understand that my information will be kept securely on file for future transactions and that I will receive a receipt for each transaction by email or paper copy if requested.

5. Alternative Imaging Services

I am aware that I have the option to receive imaging services from other facilities that accept my health insurance or imaging benefits. Choosing to obtain imaging services at Preferred Family Medicine means I may not be able to seek reimbursement from my health benefit/imaging benefit plan, even if such services are covered under my plan.

6. Impact on Medical Care

I understand that choosing to obtain imaging at another facility will in no way affect the quality of medical care I receive from Preferred Family Medicine’s healthcare professionals.

7. Patient Choice and Consent

Whether I get my diagnostic imaging at Preferred Family Medicine is entirely up to me. By signing below, I confirm that I have read and understood this information about the in-office diagnostic imaging program, have had the opportunity to ask questions, and choose to obtain my diagnostic imaging from Preferred Family Medicine under the cash-pay model described.

8. Acknowledgment of Policies

I have been informed about and understand the cancellation and refund policies of Preferred Family Medicine. I agree to adhere to these policies as part of my service agreement.

9. Consent and Agreement

By signing below, I confirm that I have read, understood, and agree to all the terms in this consent form. I acknowledge my rights to privacy and give my express permission for the uses and disclosures of information as described. I understand that I may withdraw my consents at any time, except to the extent that action has been taken in reliance upon them.
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