Patient Information
Date: 10/23/2017
Legal Last Name
Legal First Name
Legal Middle Name
Nickname
Street Address (Mailing)
City
State
Zip Code
Email
Home Phone
Alternate Phone
 
Date of Birth (mm/dd/yyyy)
MonthDayYear
Age
Marital Status
Employer
Work Phone
 
Spouse/Partner Information (If Applicable)
Spouse/Partner Name
Spouse/Partner Phone
Spouse/Partner Employer
 
Emergency Contact
Emergency Contact
Phone
Relationship
 

Have you previously been seen or treated by Dr. Cantrell or CRFIC, Inc. ? Yes
If yes, when and where were you seen?
Referring obstetrician or physician
 
Insurance Information
Primary Insurance
Employer
Subscriber
Subscribers Date of Birth (mm/dd/yyyy)
MonthDayYear
Relationship to patient
Other
 
ID / Policy #
Group #
Effective Date
Secondary Insurance
Employer
Subscriber
Subscribers Date of Birth (mm/dd/yyyy)
MonthDayYear
Relationship to patient
Other
 
ID / Policy #
Group #
Effective Date
 
Assignment of Benefits/Authorization for Treatments

I hereby authorize treatment and authorize the medical provider to release any information for these services to my insurance carrier for payment. I also authorize that payment of benefits be made to the provider on my behalf. I understand that I am financially responsible for all charges/ co-pays not covered by my insurance carrier(s), and the cost associated with collecting them.

 
Fetal Imaging Center's Office Policy

Our goal is to give you the best care available by combining the best technology with a genuine caring for you and your family, educating you at the time of the ultrasound.

Our doctor is an expert in obstetrical ultrasound and we perform the most complete ultrasounds available. Your doctor or midwife may have sent you here for a "level two", "high resolution", or "targeted" ultrasound. This means that we will be using state-of-the-art equipment to examine all the organs of the baby(ies) and some of the internal organs of the mother. We will also assess the size and health of the baby, where the placenta is and how it is working, and how much fluid there is in the sac.

Ultrasound has been used for over 25 years, and there is no evidence that it will harm you or your baby. Sound waves (far outside the range that humans can hear) are sent out from the ultrasound probe. These waves bounce off your uterus and baby and make echoes. A computer translates these echoes into pictures.

All of our ultrasounds are performed by our doctor or one of the ultrasound technologists, all of which are licensed Registered Diagnostic Medical Sonographers. This way you get a full discussion of your ultrasound while the exam is happening and additional consultation with the doctor when needed. Please feel free to ask questions during your ultrasound. We will share all available information about your baby before you leave our office. As a courtesy, we can make some photographs and/or a DVD (for a small fee) of the ultrasound if you like. We will also send the results to you doctor.

We will tell you if we feel your ultrasound is not as clear as possible, or if we want you to come back for another ultrasound to see parts of the baby more clearly. However, even under the best of circumstances, with the most experienced of doctors, not all birth defects will be seen during an ultrasound. Some organs can be seen better than others. for example, most cases of spina bifida (an opening in the spine) can be diagnosed before the baby is born, but about a third of heart defects will NOT be found until AFTER birth. An ultrasound is not good at finding functional problems such as mental retardation. (A babies brain may look normal by ultrasound but not work properly).

We need your help with your ultrasound. Other family members or friends are welcome to come with you into the ultrasound room. It is important that the physician and technologists have their full attention on your examination without the possibility of distraction. It is therefore necessary that children under the age of seven (7) not be permitted in the examination room at any time during your visit. If you arrive without an adult to stay with your child(ren) in our waiting area, it will be necessary for us to reschedule your appointment. We apologize for any inconvenience this may cause.

I acknowledge that I have read and understand this policy AND give my consent to the examination.
 
Notice of Privacy Practices
Acknowledgement of Receipt of notice of privacy practices and consent for use and disclosure of health information.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. We reserve the right to change our privacy practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health insurance that we maintain. You may obtain a copy of our Privacy Practices, including any revisions of our notice at any time by contacting Leigh Miller or Dr. Cathy Jo Cantrell at 775 828-7525 6502 S. McCarran Blvd., Suite B Reno, NV 89509. Right to revoke: You have the right to revoke this consent at any time by giving us a written notice of your revocation submitted to Dr. Cathy Jo Cantrell. Please understand that revocation of this Consent will NOT affect any action we took in reliance on this consent form.

Click here to view a copy of the Notice of Privacy Practices

I understand and acknowledge receipt of the Notice of Privacy Practices and consent for use and disclosure of health information

 
Authorization for Contact

I give my permission to leave messages as follows:
You may leave messages on my home telephone voice mailbox in regard to ANY lab results, Radiology or future appointments.
You may leave a message with anyone at my home in regard to ANY lab results, Radiology or future appointments.
You may NOT leave any messages with any other person except myself, but may leave it on my cell phone voice mail.

Cell Phone

You may NOT leave any messages of any kind on my voice mail or any person. If you can not contact me, you may email me any information if you so wish.

 
Payment Policy

We realize that every person's financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the quality care needed.

PAYMENT IN FULL is required at the time of service from all patients that do not have insurance coverage.

MEDICAL INSURANCE, we are happy to file the forms necessary to see that you receive the full benefits of your coverage; however, we cannot guarantee any estimate coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all charges. Please note that you are responsible to pay your estimated copay plus any yearly deductible at the time of each visit. We will do everything possible to see that you receive the full benefits of your policy. If for some reason your insurance has not paid their portion within 90 days from the start of treatment, you are responsible for payment at that time (including patients with secondary coverage.)

PAST DUE BALANCES are any amount owed from a prior visit where insurance is not pending or an insurance payment has not been received within 90 days (payment will be due on all balances over 90 days regardless of pending insurance claims). Any delinquent account must be paid in full before incurring any new charges.

 
Charges For Laboratory Testing

Charges for genetic studies will be billed directly from the genetic laboratory. These charges are separate from and in addition to charges for Prenatal Consultation, Ultrasound and Procedures, which will be billed from CRFIC. Your insurance may not cover these charges. It is your responsibility to verify which services are covered by your insurance. By signing below, I authorize release of all laboratory test information to my insurance carrier. I authorize the payment of benefits under this claim to be made directly to the laboratory. I understand that I am responsible for any amount not reimbursed by my insurance.

Policies are subject to change, changes will be posted in the office.


I have read and acknowledge charges for laboratory testing
 

By signing below, you are acknowledging receiving a copy of our office financial policy and that you have reviewed it and fully understand its contents. You are also signing that you have received a copy of the Notice of Privacy Practices and have had full opportunity to read and consider the contents of this Consent form and your notice of Privacy Practices.

I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care coverage.

Signature____________________________________________________________ Date_____________________
(This is to be signed upon your visit)

***If this consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representatives's Name___________________________________________
(This is to be signed upon your visit)

Relationship to the patient_________________________________________
(This is to be signed upon your visit)

 
 

Fetal Imaging Center
6502 S. McCarran Blvd. Suite B
Reno, NV 89509-6139


copyright© 2011-2012
For an appointment please call
(775) 828-7525
Email: cantrellfic@gmail.com