MRI of West Morris, P.A.l.ST High Speed Short Bore MRITown Centre at Roxbury Mall66 Sunset Strip, Suite 105, Succasunna. New Jersey 07876Tel: 973-927-1010 • Fax: 973-927-7273

PATIENT REGISTRATION

STREET ADDRESS

PRINiNAME (LonNome,FlrstNome) _

c~ _STATE__ ZIP _

HOMEPHONE _

DATE OF BIRTH _ SEX _

EMAILAOORESS _

WORKPHONE _I;MPLOYER _

~MPLOYER AODRESS _

SPOUSE'S NAMI; _

SOCIAL S€CVRITY # _

WEIGHT _ MARITAL STATUS _

CITY _ STATE__ ZIP __ ~_

SPOUSE'S EMPLOYER ~

RELATIVE'S AODRESS

NAMt; OJ: NEAREST RELATIVE (Nor living w/m you) _

PHONE _

PHONE _REFERRING DOCTOR _

PRIMARY INSURANCE

INSURANCE COMPANY _

10# _

GROUPU _

POLICY HOLDER'S NAME _

POLICY HOLDER'S DOB _

POUCY HOLOER'SSS # _

RELATIONSHIPTOPA'I1IiNT ~ --

SECONDARY INSURANCE

INSURANCE COMPANY _

ID _

GROUP# _

POLICY HOLOER'S NAME _

POLICY HOLDER'S OOB _

POLICY HOLOER'S 55 /I _

RELATIONSHIP TO PATIENT _

ISiHISTHERESULYO~ANYTYPEOfACCIDENT? 0 YES 0 NO IF YES, 0 MVA D we DATE OF ACCIDENT

ASSIGNMENT OF BENEFITS

PATIENT OR AUTHORIZED PERSON'S SIGNATURE: I authorize me release of any medical or other Information necessary toprocess this claim. I Irrevocably assign to MRI of West Morris, PA all my rights and benefits under any Insurance contracts forpayment for services rendered to me by MRI of West Morris, P.A. I Irrevocably authorize allln(ormation regarding my benefitsunder any Insurance policy relatlng to any claims by MRIof West Morris, P.A.to be released to MRIof West Morris, P.A. I Irrevocablyauthorize MRI of West Morris, P.A. to file Insurance clalrns on my behalffor services rendered to me. J Irrevocably direct that allsuch payments go directly to MRIofWe$r Morris. P,A. I Irrevocably authorize MRI of West MorrJ$,P.A.to ad in my behalf andreport ilny suspected vlctatlons of proper claims practices to the proper regulatory agency. Any unpaid balances wUl be subjectto interest from the date of service.This assignment of benefits has been explained to my full satisfa<:tlonand I understand it's nature and effect.

SIGNED ~ _ DATe _

PLEASE NOTe; Your Insurance Is a contract between you and your Insurance carrier. We will cooperate with you In processingthis claim. However, you are ultimately responsible for your financial obligations.

4000~ 0.)/1) ~.m

MRI of West Morris, P.A.1.ST Short Bore MRITown Centre at Roxbury Mall66 Sunset Strip, Suite 105, Succasunna, New Jersey 07876Tel: 973-927-1010 • Fax; 973-927-7273

PATI~NT CHECKLIST .

PR.INT NAME (Leur Name. First Name)

REFERRING PHYSICIAN

1. Do you have a pacemaker? 0 Yes 0 No2. 00 you have intercranla! dips? LJ Yes 0 No3. Are you pregnant? 0 Yes LJ No4. Have you ever had metal in your eyes? 0 Yes 0 NoS. Do you have any metal anywhere In your body? 0 Yes 0 No

If yes, where?6. Have you ever had any heart surgery? 0 Yes 0 No7. Have you ever had any brain or neck surgery? 0 Yes 0 No8. 00 you have a problem with claustrophobia? 0 Yes 0 No9. Are you taking any blood thinners? (ASpirin, Plavix, Coumadin, etc.) 0 Yes 0 No

If yes, what kind?

10. Pleasedescribe your symptoms here;

C E'RV I.e A L S PI N E . .

t. Do you have pain or numbness down your arm?If yes, which arm?

2. Have you ever had surgery on your cervical splne7

a Yeso LeftDYes

o NoCI Righto No

LUMBAR SPINE

1. 00 you have pain or numbness down your leg?If yes,which leg?

2. Have you ever had surgery on your lumbar spine?

DYeso LeftDYes

o Noo RightCJ No

BRAIN . .

1. Do you have headaches? 0 Yes 0 No2. Do you have double vision? 0 Yes 0 No3. Do you have one-sided body weakness? CI Yes 0 No

If yes, which side? 0 Left CJ Right4. Do you have hearing loss in Oneor both ears? o Yes 0 No

If yes, which side(s)? 0 Left 0 Right5. Do you have a prior history of stroke or hemorrhage? 0 Yes CJ No6. Have you had a recent head trauma? a Yes 0 No7. Have you had any previous MRI,CT, or X-Rayexamlnatlcns

of the areals) that will be scanned today? 0 Yes 0 No

If yes,where were they done?

PATIENT/GUARDIAN SIGNATURE DATE40003 O)f1l 2.500

Magnetic Imaging of Morris, ~A.MRI of West Morris, P.A.

. A C K NOW LED GEM E N T .0 F R Ec a iP T 0 F P R I.V A CY NOT ICE .. . . .' "

I have been presented with a copy of Morris MRIAssociates Notice of Privacy Policies, detailing how my protectedhealth information may be used and disclosed for treatment, payment, and healthcare operations as permittedunder federal and state law. I consent to such disclosure for these permitted uses, including disclosures via fax.I understand the contents of the Notice, and Irequest the following restriction(s} concerning the use of my personalmedical information:

I understand that the practice is not required to agree to the restrictions requested. Further, I permit a copy of thisauthorization to be used in place of the original, and understand that this document will remain in effect for 7(seven) years from the original date of signing. I further understand that Imay request additional restrictions, inwriting, at any time by sending a request to the following address:

MRIof West Morris, PAAttn: Privacy Officer66 Sunset Strip, Suite 105Succasunna,NJ 07876

Signed: _ Date: _

If not signed by patient, please indicate relationship to patient (e.g. spouse)

Relationship: _ Witnessed by _

FOR OFFICE USE ONLY:

o Acknowledgement signed

o Signature refused by patient, and exam performed as permitted

o Signature refused by patient, and exam refused as permitted

o Acknowledgement added to the patient's medical record on

Employee Name Date

20002

Magnetic Imaging of Morris, P.A.Open MRI &: 1.ST High Speed Short Bore MRI420 Boulevard, Suite 103, Mountain Lakes, New Jersey 07046Tel: 973-402-9111 . Fax: 973-402-7620

MRI of West Morris, P.A.1.5T High Speed Short Bore MRITown Centre at Roxbury Mall66 Sunset Strip, Suite 105, Succasunna, New Jersey 07876Tel: 973-927-1010 • Fax: 973-927-7273

AUT H 0 R I Z A T ION IRE FER R.A L .P 0 Lie V

Many insurance companies have strict guidelines and policies with respectto authorizations and referrals for MRI procedures. Because these policieschange on a regular basis, it is the responsibility of the patient to know whatinformation is needed and what guidelines must be met according to his orher insurance company's policies in order to have an MRI examination.

I understand that I, the patient, am responsible for any payment related toany procedure for which I did not properly obtain a referral, or any proce-dure that I did not have properly authorized or pre-certified.

PRINT PATIENT'S NAME

SIGNATURE

DATE

Meeting All of Your MRI Needs

10002 0112013 2.500