Medical Imaging is utilizing technology to make having a radiological exam not only precise but patient-friendly. For your convenience, here are the various forms that patients are asked to fill out. Download and print!
 

Patient Registration
This is the most common form all patients are asked to fill out once they arrive.
Patient Registration form >>

Transferring from another Facility: You have a choice!

It is very important for the radiologist to have access to all of a patient’s mammography films so that he or she may evaluate changes in breast tissue over time. For patients who have had mammograms at another facility, but wish to make the switch to Medical Imaging, there are two easy options:

1. Pick up your films (in person) from the previous facility and bring them with you to your appointment at Medical Imaging.  Many facilities require 48 hours advanced notice to prepare your films for pick-up, so make sure to call ahead and let them know you will be picking up your films.  The radiologist will be able to view all of your films at the time of the mammogram and discuss your results with you.

2. At the time of your Medical Imaging appointment, you may sign an Outside Release of Records form.
This one would be used if you wish to have another medical facility release your medical records to us. It's very often used when a patient moves her mammograms from another facility to ours.

North Oak facility form >>
Eastland Facility >>

This process sometimes takes several days or more because the films are often sent via mail.  As soon as Medical Imaging receives your previous films, the radiologist can view them, and send written results to you and your referring doctor.   There is no charge to the patient for the film retrieval service.
 

 
HIPAA Signature and HIPAA Privacy forms
You will be asked to sign the HIPAA Signature form, acknowledging that you have read the HIPAA Privacy Notice.We've included Medical Imaging's Privacy Notice for your review prior to filling out the Signature form.
Signature form >>    Privacy notice form >>

 
Outside Release of Records   
This one would be used if you wish to have another medical facility release your medical records to us. It's very often used when a patient moves her mammograms from another facility to ours.
North Oak facility form >>   Eastland facility form >>

 
Pre-Exam Interview  
This form is used if you are going to have a CT scan.
Pre-Exam Interview form >>

 
Advance Beneficiary Notice (ABN)
This form is used when Medicare patients are scheduled to have certain procedures done. Those procedures are listed on the form.
ABN form >>

 
Mammogram History 
Patients coming in for a mammogram will be asked to fill this out.
Mammogram History form >>

 
Osteoporosis Data Sheet    
You would be asked to fill this out before a Bone Density scan.
Osteoporosis Data Sheet form >>

 
Film Checkout 
Medical Imaging will provide you with films or CD's of your exam at no charge. CD's are the preferred choice; they self-launch (requiring no special software to run), are vastly more detailed, and (most importantly) much, much smaller and easier to store. Many doctors however will still request the films of your exam, and we of course will continue to provide these. Note that while Medical Imaging has largely converted to digital radiology equipment, XRays are still stored only on film sheets. If you take those, we will need those back. This form acknowledges that we have released the CD or film of your exam to you.
Film Checkout form >>

 
Financial Responsibility
You may be asked to fill this out if you are seeing us for an exam covered under Workmen's Compensation.
Financial Responsibility form >>

 
Exam Request Form
Reffering offices in need of an Exam Request form can use the link below to access one.
Exam Request Form >>