DATE NAME: DOB: / / AGE: ADDRESS: CELL PHONE NUMBER/BEST CONTACT NUMBER: REFERRING PHYSICIAN: EMERGENCY CONTACT NAME, PHONE NUMBER

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1 Mammosafe 5300 North Braeswood Boulevard Suite Houston, Texas BREAST HISTORY FORM DATE NAME: DOB: / / AGE: ADDRESS: CELL PHONE NUMBER/BEST CONTACT NUMBER: REFERRING PHYSICIAN: EMERGENCY CONTACT NAME, PHONE NUMBER Is this your first mammogram? YES NO and my last mammogram was performed at on (date or year) When did you last have a breast exam performed by your doctor? Do you currently have any breast problems? NO YES and I would describe my current breast problems as: right left both Do you have breast implants? NO YES and they were placed in (year) Have you ever had a breast biopsy or breast surgery? NO YES and the breast procedure was performed for (reason) right left both in (year) at (location) Have you ever had breast cancer? NO YES right left both diagnosed in (year) and I was treated at (location) and I completed treatment in (year) Please list family members who have had breast cancer and at what age they were diagnosed with breast cancer: Have you had a hysterectomy? NO YES and in (year) Have your ovaries been removed? NO YES and in (year)

2 Are you currently taking female hormones? NO YES and I have been taking them for (how many years) Did you start taking female hormones since your last mammogram NO YES or did you stop taking female hormones since your last mammogram NO YES? Have you had a weight change since your last mammogram? NO YES and I have LOST GAINED about (number of pounds) Please list any allergies you have: Please list any medical conditions you have: NONE or MY MEDICAL CONDITIONS ARE Please list the medications you take regularly: NONE or I take the following medications: My height is feet inches and I weigh pounds Are you currently pregnant? NO YES. Answer confirmed by tech (initials) Are you currently breastfeeding? NO or NO, but I recently stopped breastfeeding in (month and year) or YES, I am currently breastfeeding. FOR OFFICE USE ONLY COMMENTS: DETAILS IF PERSONAL HISTORY OF BREAST CANCER: TECHNOLOGIST INITIALS:

3 Mammosafe 5300 North Braeswood Boulevard Suite Houston, Texas CONSENT FOR SCREENING MAMMOGRAPHY AND INDICATED BREAST IMAGING PROCEDURES SUCH AS DIAGNOSTIC MAMMOGRAPHY AND BREAST ULTRASOUND TO BE PERFORMED UNDER THE DIRECTION OF DANIEL R. ROUBEIN, M.D. Mammography is an accurate method to detect breast cancer. However, I understand that mammography does not detect all breast cancers or breast diseases. I understand that compression of the breasts is necessary in order to obtain the best exam possible. If I have breast implants, I understand that I should advise the mammography technologist before my mammogram is performed. I have been advised that problems caused by compression, such as implant rupture, are rare but can occur, especially in older or weakened implants. Mammosafe utilizes the newest FDA approved computer aided detection system, VuComp, for the screening mammograms it performs. This assists the radiologist by bringing subtle changes in the appearance of the breast tissue, which may indicate the presence of cancer, to the radiologist s attention. Dr. Roubein is an experienced radiologist who has been interpreting screening mammograms and other breast imaging studies for over twenty years. I understand, though, that no radiologist is perfect and no mammogram is perfect. This means that not every breast cancer is diagnosed on every mammogram performed, whether here at Mammosafe with Dr. Roubein or at any other appropriately accredited and licensed mammography facility. I understand that Dr. Roubein pledges to do his best in his interpretation of my screening mammogram and other breast imaging procedures. I consent to have my screening mammogram and other indicated breast imaging procedures performed by Mammosafe. I accept Dr. Roubein s best efforts as meeting the standard of care. This means that I understand and accept that Dr. Roubein s interpretation of my mammogram and other breast imaging studies meets the standard which would be exercised by a reasonably prudent radiologist rendering an interpretation of my mammogram under the same circumstances. / / / Printed Name of Patient Patient s Signature Witness Date

4 MAMMOSAFE AUTHORIZATION FOR RELEASE AND USE OF PROTECTED HEALTH INFORMATION PATIENT NAME: DOB: / / ADDRESS: HOME PHONE: CELL PHONE: I hereby authorize the release of all my imaging studies and reports and treatment records and protected health information including film, CD and medical reports. PLEASE SEND ONLY BREAST IMAGING STUDIES AND REPORTS AT THIS TIME. This information should be sent to: Mammosafe 5300 North Braeswood Boulevard Suite Houston, Texas WHERE WAS YOUR YOUR LAST MAMMOGRAM PERFORMED? Date/Year of last mammogram If I need protected health information in the possession of Mammosafe sent to another facility, I give Mammosafe my permission to release this protected health information, including film, CD and final reports. I understand that I have the right to refuse to sign this authorization. I also understand that I may revoke this authorization at any time by providing written notice to Mammosafe. This authorization will expire one year from the date signed below. Signature: Date: Signature of Witness:

5 MAMMOSAFE FINANCIAL POLICY AND PRIVACY POLICY Date Patient Name Date of Birth / / Please check here if you do not have health insurance and proceed to the next page. Patients with insurance please continue here. Mammosafe is committed to making your experience with us as pleasant as possible. In the majority of cases, and as a service to you, we will submit your claim to your insurance company under the benefit coverage you specify. However, your agreement with your insurance carrier is a private one. We can assist with, but are not solely responsible to research, why an insurance carrier has not paid or why it has paid less than anticipated. Please understand that, ultimately, you, as the patient, are responsible for payment of the account, including any balance not covered by insurance. At the time of your visit, you are responsible for the payment of any known co-payment, unmet deductible or non-covered service. In the event that your insurance company does not make payment within 45 days, the unpaid balance becomes your responsibility. If you have questions or concerns about billing, please call us at I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans, to Mammosafe for the purpose of payment to Mammosafe for services rendered to me by Mammosafe. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as a valid original. I understand that I am financially responsible for all Mammosafe charges whether or not paid by said insurance. I hereby authorize Mammosafe to release all information necessary to secure the payment. I have read, understood and agree to the above financial policy for payment of technical and professional fees. I understand that I am ultimately responsible for the payment of all Mammosafe fees. PLEASE CIRCLE ONE: I have met my insurance deductible for the calendar year: YES NO UNSURE Patient Signature

6 Please check here if you do not have Medicare and proceed to the NOTICE OF PRIVACY PRACTICES SECTION at the bottom of this page. Continue Here If You Have Medicare Mammosafe accepts assignment on all Medicare claims. We will bill Medicare for you. We will also bill secondary insurance carriers for you. All copayments, deductibles, and non-covered services are due at the time service is rendered. If you have questions about Medicare billing, call (TTY: ). I request payment of authorized Medicare benefits be made on my behalf to Mammosafe for any services furnished to me by Mammosafe. I authorize any holder of medical information about me to release to Centers for Medicare/Medicaid Services and its agents any information needed to determine these benefits for the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. Patient Signature Patient s Medicare number Medicaid Patients All Medicaid patients must provide current participation information. ALL PATIENTS: NOTICE OF PRIVACY PRACTICES Please ask us if you have any questions about the policy. I acknowledge receipt of, and understanding of, the Mammosafe notice of Privacy Practices. Patient Signature: Date:

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