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Consent Form

Magnetic Resonance Imaging (MRI) is one of the most advanced and informative diagnostic procedures. MRI is a method of obtaining images of structures inside of your body by utilizing a large magnet and radio waves, but does not involve any radiation. At American Dynamic Imaging (ADI), we have the Fonar Upright MRI machine which is a .6 Tesla strength.

MRI AWARENESS AND CONSENT:

I am aware that MRI uses a strong magnetic field and can damage Cell Phone, Credit Cards, Watches, and Hearing aids.
I am aware that American Dynamic Imaging (ADI) will provide a locked area for me to place my belongings.
I am aware that I am required to notify technologist on duty if I am pregnant or if I have metallic devices or implants.
I am aware that my referring doctor will receive a copy of my medical records and it is typically their wish to go over these records with me at my next appointment.
I am aware that my medical records are available from ADI for seven years.
I consent that I have described my symptoms and medical history to the best of my ability.

MY AUTHORIZATION WITH THE ADI FACILITY INCLUDES:

My authorization for treatment at the ADI facility.
My authorization to release medical information including reports, images, etc. to my referring doctor, any medical specialist I visit and/or my insurance company.
My authorization to release medical information to the person listed here, if directed:

Name of Person for Release of My Medical Information *

My authorization for payment of medical benefits to be paid directly to the ADI facility.
My authorization for referring doctors to release medical information to ADI facility.
My authorization for other providers of care to release information which is relative to my MRI today, such as labs, previous images, studies, or reports to ADI facility.
My authorization to be contacted by text or email in regards to future scheduling, billing, and/or other communication.

MY AGREEMENT WITH THE ADI FACILITY INCLUDES:

My signature below confirms that I am 18 years or older and able to give medical consent for myself or I am the legal guardian for the patient.
My understanding that I may be billed for any amounts not covered by my insurance company.
My understanding that I will receive a statement for services rendered and payment is due upon receipt.
My understanding that I will not receive a refund for MI scans completed with diagnostic radiologist report for any purposes except for overpayment due to insurance.
ADI will contact my doctor regarding my referral to the facility.
ADI will contact my insurance company regarding my referral to the facility.
ADI will exhaust all valid insurance avenues prior to billing me.
ADI will respect my privacy with normal industry standards.
ADI will provide me a copy of their HIPAA practices if I so request.
ADI will forward the results of my MRI to the referring doctor and/or requesting specialists.

By signing below, I certify that I have read and agree to the above awareness, consent, and authorization and give consent for American Dynamic Imaging to perform the requested MRI.

* Indicates required field

Type Full Name in Lieu of Signature *

Date Signed *

Email *

Phone Number *

Name of Patient Representative, if applicable *

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