Authorization for Release of Information – Compound Release
Name of Patient ___________________________________________ Date of Birth ______________
COASTAL RADIOLOGY ASSOCIATES is authorized to release protected health information about the
above named patient in the following manner and to identified persons.
Entity to Receive Information.
Check each person/entity that you approve to receive
information.
Description of information to be released. Check each
that can be given to person/entity on the left in the same
section.
 Voice Mail
 Results of lab tests/x-rays
Other_______________________________
 Spouse (provide name and phone number)
______________________________________
 Parent (provide name and phone number)
__________________________________
 Email communication-Provide email address*
____________________________________
*In order for email communication to occur, please accept
the disclosure below:
 Financial
 Medical
 Financial
 Medical
 Financial
 Medical
 Breach notification
 By electing email communication, I understand this method of communication may not be encrypted and is considered
unsecure. I further understand there is a risk that this could be accessed inappropriately. I still elect to receive email
communication.
 I authorize this office to send me marketing communications about products and services on behalf of a third party for
which this office may be compensated for.
Patient Rights:
 I have the right to revoke this authorization at any time.
 I may inspect or copy the protected health information to be disclosed as described in this document.
 Revocation is not effective in cases where the information has already been disclosed but will be effective
going forward.
 Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient
and may no longer be protected by federal or state law.
 I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
The information is released at the patient’s request and this authorization will remain in effect until
revoked by the patient.
_________________________________________________________
Signature of Patient or Personal Representative
*Description of Personal Representative’s Authority (attach necessary documentation)
Date ___________________
Patient Registration Form (PLEASE PRINT CLEARLY)
*Patient's Name:____________________________________________________________________________
First Name
Middle Initial
Last Name
Nickname: ________________________________Suffix:___________________SSN#:__________________________
*Date of Birth: ____________________
* Gender: □ Male □ Female
Martial Status: □ Single □ Married □ Widowed □ Divorced □ Separated
*Race: ___ American Indian or Alaska Native ___ Asian ___ Black or African American ___Native Hawaiian or Other
Pacific Islander __ Other ___ Unknown ___ White ___ Decline to Answer
*Ethnicity: ___ Hispanic or Latino ___ Not Hispanic or Latino ___ Declined to Answer
*Language: ___ English ___ Spanish ___ French ___ German _____ Other: ____________________________
Street Address:___________________________________________________________________________________
City/State/Zip Code:_________________________________________________________________________________
Home Phone Number w/Area Code: ______________Cell Phone Number w/Area Code: _________________________
Occupation: ___________________________________Employer: _________________________________
Work Phone Number w/Area Code:__________________________________________________________________
E-mail: ____________________________________________Preferred Communication: _________________________
*Pharmacy Name: __________________________________ Pharmacy Number:__________________________
Primary Physician: ________________________________________Referring Physician: ________________________
*How did you hear about the clinic? □ Airport □ Internet □ Newspaper □ Yellow Pages □ Other: _____________________
Spouse's or Parent's Name: ______________________________ Home Number w/Area Code: ___________________
Cell Phone w/Area Code: ________________________________Work Number w/Area Code: _____________________
In case of emergency, contact (not living with you): _______________________________________________________
Street Address: ____________________________________________________________________________________
City/State/Zip Code: _________________________________________________________________________________
Home Phone Number w/Area Code: _______________Cell Phone Number w/Area Code: _________________________
Work Phone Number w/Area Code: ____________________________________________________________________
Relationship to Patient: _____________________________________
In case of emergency, contact (not living with you): ________________________________________________________
Street Address: ____________________________________________________________________________
City/State/Zip Code:
_________________________________________________________________________________________________
Home Phone Number w/Area Code: _____________________Cell Phone Number w/Area Code:_________________
Work Phone Number w/Area Code: ___________________________________________________________________
Relationship to Patient: _____________________________________
*PLEASE PRESENT INSURANCE CARD(S) & PHOTO FOR SCANNING AND COMPLETE THE REQUESTED INFORMATION*
Insurance Company #1: __________________________Phone Number: ______________________________________
Primary Insurer's Name: _______________________________Date of Birth: __________________________________
Policy# _____________________________ Group #: _______________Relationship: ____________________________
Insurance Company #2: _______________________________________Phone Number: __________________________
Primary Insurer's Name: ______________________________________Date of Birth: ____________________________
Policy# _____________________________ Group #: _______________ Relationship: ____________________________
Responsible Party:__________________________ Relationship: □ Self □ Spouse □ Parent □ Other: ________________


I hereby authorize the payment of medical benefits to Coastal Radiology for services rendered. I understand that
I am financially responsible for any services not covered by my insurance carrier.
I further agree to pay all collections costs, attorney fees, and other collections costs that may be incurred to
enforce the collection of any amounts outstanding.
I hereby authorize Coastal Radiology to release any medical information necessary to complete and process my
insurance claims.
______________________________________________________________
____________________
Patient's or Insurer's Signature (If patient is a MINOR, must have Responsible Party Signature)
Date
I authorize physicians at Coastal Radiology Associates , PLLC to treat me and use my personal health information for
healthcare operations.
_______________________________________________________________ _______
Patient's Signature (OR Parent if patient is a Minor)
__________________________
Date
Patient Questionnaire
Height: __________ Weight: __________lbs
1. Have you had a Flu Vaccine this year?
YES
2. Have you ever had a Pneumococcal Vaccine?
NO
YES
NO
3. For women only, have you had a mammogram within the last two years?
YES
NO
4. For patients whose primary diagnosis is back pain, when did your back pain start?
__________________________________________________________________
a. Have you had an x-ray, CT, Bone Scan or MRI of your
back? ________________________
b. If so, when did you have the study? ___________________________
5. For men 60 years and older, have you ever been screened for an abdominal aortic
aneurysm?
YES
NO
6. Are you a smoker?
YES NO
a. If yes, how many years have you smoked? __________
b. How many packs per day? __________
7. Do you use tobacco? YES
8. Do you drink alcohol?
YES
NO
If yes, please indicate use? _______________
NO
How often? ________________________
___________________________________________________________________
Patient Name (PRINT) Date