Mammogram Form

NOTE

If you haven't already done so, please don't forget to accomplish the Release Form. Click on the link below to open the form in another window.

Patient Release Form

Have you ever had an Ultrasound or Breast MRI? *

Have you had any of the following breast procedures? (Check all that apply)
Breast Implants
Needle Biopsy
Cyst Aspiration
Surgical Biopsy
Reduction
Lumpectomy / Cancer removal
Mastectomy
Radiation Therapy
Family history of breast cancer
Henda's Law - Effective: January 2012
"If your mammogram demonstrates that you have dense breast tissue, which could hide abnormalities, and you have other risk factors for breast cancer that have been identified, you might benefit from supplemental screening tests that may be suggested by your ordering physician. Dense breast tissue, in and of itself, is a relatively common condition. Therefore, this information is not provided to cause undue concern, but rather to raise your awareness and to promote discussion with your physician regarding the presence of other risk factors, in addition to dense breast tissue."

A report of your mammogram results will be sent to your physician. You should contact your physician if you have any questions or concerns regarding this report.

Technologist Section

Breast Imaging Release Form

I AUTHORIZE THE RELEASE OF ALL MAMMOGRAMS / BREAST IMAGING ON CD AND/OR REPORTS AS SPECIFIED BELOW:

PHYSICIAN / FACILITY NAME: *
PHONE: *
FAX: *
MAILTO:
  • GLOBAL IMAGING, LLP
  • Attention: MAMMOGRAPHY
  • 1435 HIGHWAY 6-SUITE 102
  • SUGAR LAND, TEXAS 77478
  • FAX: 281.313.1705
REASON FOR RELEASE

I understand that the information released is for specific purpose stated above. Any other use of this information without the patient’s written consent is prohibited.

PLEASE FAX BACK IF

Office use only - checkall that apply

Patient Information Consent Form

Please initial lines 1-5
1.

It is understood that the diagnostic procedure(s) ordered by my physician will be performed by Global Imaging and do hereby authorize and consent to such service.

2.

I hereby authorize Global Imaging to release any medical information regarding the services performed to my personal physician, insurance company, and or employer (in the event of a worker’s compensation injury).

3.

A quote of benefits and/or authorization does not guarantee payment from your insurance companies. It is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. The undersigned hereby agrees to pay all charges not covered by the health nsurance company. Any balance not paid within 90 days after the date of service will be considered in default unless financial arrangements have been made with the business office.

4.

I acknowledge I have read and agree with the HIPAA policy. If for any reason I am unable to pick up my personal records, I understand Global Imaging office policy requires proof of family/friend identity to release my information.

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or otherwise as permitted by such regulations.

A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR THIS PURPOSE.

5.

I consent to receive text messages and emails from Global Imaging, LLP. I understand that this request to receive emails and text messages will apply to all future appointment reminders and updates.

I, the undersigned, have read the above and authorize the staff of Global Imaging to disclose such information as herein contained.