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39180 Farewell Drive, Suite 110B Fremont, CA 94538 Phone: 5105852296 Fax: 8668575474 www.fremontopenmri.com Patient Consent Form The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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How to fill out open-mri-fremont-patient-consent-form-12-29-13docx:

01
Start by carefully reading the entire form to understand its purpose and the information it requires.
02
Fill in your personal information accurately, including your full name, address, phone number, and date of birth.
03
Provide your medical history, including any existing medical conditions, allergies, and current medications you are taking.
04
If applicable, indicate any previous surgeries or medical procedures you have undergone.
05
Review the consent section of the form and make sure you understand the risks and benefits of the MRI procedure. If you have any questions, seek clarification from the healthcare provider.
06
If there are any limitations or restrictions to the MRI procedure, make sure to disclose them accurately on the form.
07
Once you have completed all the necessary sections, sign and date the form to indicate your consent and understanding.
08
Make a copy of the filled-out form for your records.

Who needs open-mri-fremont-patient-consent-form-12-29-13docx:

01
Patients who are scheduled to undergo an MRI procedure at the Fremont facility.
02
Individuals who have been advised by their healthcare provider to undergo an MRI examination.
03
Any person who needs to provide consent for their medical information to be used and shared for the purpose of the MRI procedure.
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open-mri-fremont-patient-consent-form-12-29-13docx is a document that patients at Open MRI Fremont are required to consent to before undergoing a procedure.
Patients at Open MRI Fremont are required to file the open-mri-fremont-patient-consent-form-12-29-13docx before undergoing a procedure.
Patients are required to fill out the open-mri-fremont-patient-consent-form-12-29-13docx by providing their personal information and signing to consent to the procedure.
The purpose of open-mri-fremont-patient-consent-form-12-29-13docx is to obtain the patient's consent before they undergo a procedure at Open MRI Fremont.
The open-mri-fremont-patient-consent-form-12-29-13docx must include the patient's personal information, medical history, and consent to the procedure.
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