SCHAFFER, SCHONHOLZ & DROSSMAN. LLP — BREAST MRI

SCHAFFER, SCHONHOLZ & DROSSMAN. LLP — BREAST MRI 315 West 57th Street (between 8TH Avenue and 9" Avenue) Tel: New York. New York 10019 Fax: PATIENT'S NAME APPOINTMENT DATE: REF PHYSICIAN: BREAST MRI APPPOINTMENT INFORMATION 2- \lc) \Coi Kc MRI PACKET PROVIDED TO PATIENT ON: TIME: X. s MRN: SCHEDULER: in office 0 USPS mail 0 At your physician's request. you have been scheduled for an MRI examination of the breast. The examination will be performed at cur Breast MRI office located on the Concourse Level at 315 West 57' Street between 8th and 9th Avenue. Below. you will find important information regarding the procedure. Please read these instructions carefully and call our office at 212.755.7656 if you have any questions. • Please arrive to the MRI Office at your scheduled lime so you can review your identifying documentation and prepare for the examination. • The day before your appointment. PLEASE DRINK six to eight 8oz GLASSES OF WATER. • If you are 60 years old or over or have a history of diabetes or renal disease, a recent (within two weeks of your appointment) BUN and Creatlnine blood test is required to assess renal function in association with a contrast agent which may be administered during your MRI examination. Should these results not be available at the time of your examination, a "finger-stick" laboratory screening test will be performed just prior to your MRI examination. NOTE: If you are having the MRI exam for assessment of breast implant rupture, the previous two paragraphs do not apply to you.) • Bring your completed MRI Screening sheet. • You may continue to take all medications you currently take as prescribed. • It is extremely important to bring any previous studies related to this procedure for comparison with your current examination. If you have any films related to this procedure please bring them with you. • Also, if your Referring Physician has given you any notes that pertain to the study, please bring those with you as well. • Allow one to one and a half hours for the MRI exam. • Our Physicians will contact you within 48 hours to discuss the MRI results. A detailed medical report will be sent to your Referring Physician. BILLING PROCEDURES The fee for the procedure(s) that has been scheduled is: S Please be advised that our office does not participate with any commercial insurance plans. The foe for this examination will be billed to you to the address we have on file. Please note that most insurance companies require pre-certification for this examination. We suggest that you contact your Insurance carrier for information regarding pre-certification requirements so you may be reimbursed for this service according to your policy's allowances. If you have any billing questions, please call our Billing Department at 212-755-7656 Ext 17 • PLEASE SEE OTHER ATTACHMENTS FOR ADDITIONAL INFORMATION • EFTA00520767 DIRECTIONS TO THE MRI OFFICE The Breast MRI office is located at 315 West 571h Street between 8th and 9 th Avenues - Concourse Level, Suite LL4 Transportation: o By Subway: A, B, C, D or 1 to Columbus Circle o By Bus: M5, M6, M7, M30, M31, M57 and M104 stop nearby. Parking: o The nearest parking facility is on 571° Street between 8th and 91° Avenue - directly across the street from our office. • C. • 77-77-"ritrarreP517. lerrnaferk7r_nrr--4-47 reirtsere- rtretarec, EFTA00520768 Schaffer, Schonholz & Drossman, LLP — Breast MRI 315 West 57'" Street - Concourse Level Tel New York, New York 10019 Fax BREAST MRI GUIDELINES • Please bring anything in writing from your referring doctor. • Take all medications as prescribed. • Leave all valuables at home. • Allow one hour for each MRI exam scheduled. • Results will be sent to your referring doctor in 2-3 business days. • Please call us prior to appointment if you are pregnant or have a cardiac pacemaker, cardiac valves, implanted cardiac defibrillator, aneurysm clips, cochlear ear implants, heart stents, and retinal implants. • Your appointment time includes a 15 minute registration period. IMPORTANT; The MRI must be performed on days 7 - 12 of your menstrual cycle. • The day before and the day after your MRI examination, PLEASE DRINK SIX TO EIGHT 8oz glasses of water. • If you are 60 years old or over, or have a history of diabetes, renal disease or are on dialysis, please inform us when you schedule your appointment. We will need results of a recent (within 2 weeks of your appointment) BUN and Creatinine blood test to assess renal function in association with the contrast agent which may be administered during your MRI examination. If you have any questions or concerns, please call our office at EFTA00520769 Patient's Name: SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 488 Madison Avenue • New York, NY 10022 31! West 57" Street • New York, NY 10019 PRE-CERTIFICATION INFORMATION DOB: I am aware that the MRI procedure I have scheduled may need to be pre-certified by my insurance carrier in order for me to receive full or partial reimbursement. I am aware that the pre-certification process may take several days to be completed and that it is my responsibility to initiate the process in a timely fashion. I am aware that I am responsible for the full fee as stated below. 2( Breast MRI o MRI Guided Breast Biopsy o MRI Guided Wire Localization $ 2,200.00 $ 3,600.00 $ 2,700.00 Patient's Signature:1( Date: EFTA00520770 SCHAFFER, SCHONHOLZ & DROSSNIAN, LLP 315 West 57th Street - LL4 New York, NY 10019 Patient's Name: Date of Exam: .Bwkayfrilirgigytscmgittiqp.HEn (Plen,. print legibly) Mc 0: MRN: Age: • DOB: Sex: F Tel: 11. 1 Fax: Have you had a prior mammogram: 0 Yes 0 No Where?: Have you had arecent clinical breast exam by your physician/practitioner (within the past year)? ODYaetes: 0 No Reason for Today's Exam: 0 Annual screening exam (no problems) 1St Last CBE Date: 0 Diagnostic Exam (Check all that apply) 0 Left 0 Right 0 Both 0 NEW lumps in your breast? 0 NEW pain in your breast? 0 Abnormal discharge from nipple? family History: Do you have a family history of breast cancer? If yes, who? who? Personal History: Have you ever had breast cancer? If yes, please check the following boxes: Which breast? What surgery? Radiation therapy? Type of cancer? Are you BRCA positive? (Breast cancer gene) Surgical History: Have you ever had ANY previous breast surgery? If yes, please check the following boxes: Medical Information: Are you pregnant? 0 Yes 0 No Benign excision Aspiration Needle biopsy Breast reduction/breast lift Implants 0 6 month follow-up exam 0 Call back examination 0 Other changes? Explain: O Yes 0 No Age when diagnosed? Age when diagnosed? O Yes 0 No When? O Left 0 Right 0 Both O Mastectomy 0 Lumpectomy (for breast cancer) 0 Yes 0 No 0 Invasive 0 DCIS 0 Not sure 0 Yes 0 No 0 Have not been tested O Yes 0 No O Left 0 Right 0 Both When? O Left 0 Right 0 Both When? O Left 0 Right 0 Both When? 0 Yes 0 No When? 0 Yes 0 No When? implant Type 0 Silicone 0 Saline Are you currently breast feeding? 0 Yes 0 No Do you have monthly menstrual periods? 0 Yes 0 No (post menopausal) 0 No (post hysterectomy) Date of last menstrual period: Are you on hormone supplement? 0 Yes 0 No Are you on birth control? 0 Yes 0 No Personal history of any cancer other than breast cancer? 0 Yes 0 No Explain: Personal history of any other medical condition? 0 Yes 0 No Explain: Patient Signature: Date: Technologist initials: EFTA00520771 SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 315 West 57th Street - LL4 New York, NY 10019 Tel: Fax: PATIENT MEDICATION GUIDE FOR GADOLINIUM-BASED CONTRAST Patient Name: MRN: Contrast Type Being Administered: S00tarem nEoviSt DMullThance D0ther: A The United States Food & Drug Administration requires imaging centers to share this information with patients scheduled to receive gadolinium-based contrast agents for magnetic resonance imaging. What is a GADOLINIUM-BASED CONTRAST AGENT (GBCA)? • The injection you are scheduled to receive is a prescription medicine called a gadolinium-based contrast agent (GBCA). GBCAs are injected into your vein and used with a magnetic resonance Imaging (MRI) scanner. • An MRI exam with a GBCA helps your doctor to see problems better than an MRI exam without a GBCA. • Your doctor has reviewed your medical records and determined that you would benefit from using GBCA with your MRI. What Is the most important Information I should know about GADOLINIUM-BASED CONTRAST AGENTS? • This injection contains a metal called gadolinium. Small amounts of gadolinium can stay in your body including the brain, bones, skin and other parts of your body for a long time (several months to years). • His not known how GBCAs may affect you, but solar, studies have not found harmful effects in patients with normal kidneys. • Rarely patients have reported pains, tiredness, and skin, muscle or bone ailments for a long time, but these symptoms have not been directly linked to gadolinium. • There are different GBCAs that can be used for your MRI exam. The amount of gadolinium that stays In the body is different for different gadolinium medicines. Gadolinium stays In the body more after Omniscan or Optimark than after Eovist, Magnevist or MulliHance. Gadolinium stays in the body the least after Dotarem, Gadavist or ProHance. • People who get many doses of gadolinium medicines, women who are pregnant and young children may be at increased risk from gadolinium staying in the body. • Some people with kidney problems who get gadolinium medicines can develop a condition with severe thickening of the skin, muscles and other organs in the body (nephrogenic systemic fibrosis). Your healthcare provider should screen you to see how well your kidneys are working before you receive GADOLINIUM-BASED CONTRAST. Do not receive a GADOLINIUM-BASED CONTRAST if you have had a prior severe allergic reaction to it. Before receiving GADOLINIUM-BASED CONTRAST, tell us about all your medical conditions, including If you: • Have had any MRI procedures in the past where you received a GBCA. Your healthcare provider may ask you for more information including the dates of these MRI procedures. • Are pregnant or plan to become pregnant. It is not knoWn if GADOLINIUM CONTRAST can harm your unborn baby. Talk to your healthcare provider about the possible risks to an unborn baby if a GBCA is received during pregnancy. • Have kidney problems. diabetes, or high blood pressure. • Have had an allergic reaction to dyes (contrast agents) including GBCAs. What are possible side effects of GADOLINIUM-BASED CONTRAST? • See above 'What is the most important information I should know aboutGADOLINIUM-BASED CONTRAST AGENTS?". • Allergic reactions: GADOLINIUM-BASED CONTRAST can cause allergic reactions that can sometimes be serious. Your healthcare provider will monitor you closely for symptoms of an allergic reaction. Most common side effects of GBCAS: Nausea, headache, dizziness and cold feeling or burning at the injection site. Other common side effects can include: Rash, pain, vasodllatlon, tingling in hands or feet, and taste perversion. These are not all the possible side effects of GADOLINIUM-BASED CONTRASTAGENTS. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1.800-FDA-1088. General Information about the safe and effective uses and Ingredients of GADOLINIUM-BASED CONTRAST. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. You can ask your healthcare provider for information about GADOLINIUM-BASED CONTRAST that is written for health professionals. Dotarem Active Ingredient: Gadoterate meglumine Inactive Ingredients: DOTA water erbet Gui e approv y the FDA 4/2018 Eovist Active Ingredient: Gadoxelate disodium Inactive Ingredients: Caloxetate trisodium, trometamol, hydrochloric acid and/or sodium hydroxide (for pH), water Manufacturer: Bayer HealthCare h rrnaceuticals e approv by the FDA 4/2018 MultlHance Active Ingredient: Gadobenale dimeglumine Inactive Ingredient: water Manufacturer. Bracco Dia A 4/2018 I acknowledge that I was provided the above Information regardin Gadolinium-Based Contrast Agents. Patient Signature: Witness Signature: Date: Job Title: EFTA00520772 MEDICATION GUIDE DOTAREM® (doh TAH rem) (gadoterate meglumine) Injection for Intravenous use What Is DOTAREM? • DOTAREM is a prescription medicine called a gadolinium-based contrast agent (GBCA). DOTAREM, like other GBCAs, Is injected into your vein and used with a magnetic resonance Imaging (MRI) scanner. • An MRI exam with a GBCA, Including DOTAREM, helps your doctor to see problems better than an MRI exam without a GBCA. • Your doctor has reviewed your medical records and has determined that you would benefit from using a GBCA with your MRI exam. What is the most Important information I should know about DOTAREM? • DOTAREM contains a metal called gadolinium. Small amounts of gadolinium can stay in your body including the brain, bones, skin and other parts of your body for a long time (several months to years). • It is not known how gadolinium may affect you, but so far, studies have not found harmful effects in patients with normal kidneys. • Rarely patients have reported pains, tiredness, and skin, muscle or bone ailments for a long time, but these symptoms have not been directly linked to gadolinium. • There are different GBCAs that can be used for your MRI exam. The amount of gadolinium that stays In the body Is different for different gadolinium medicines. Gadolinium stays in the body more after Omniscan or Optimark than after Eovist, Magnevist or MultiHance. Gadolinium stays in the body the least after Dotarem, Gadavist or ProHance. • People who get many doses of gadolinium medicines, women who are pregnant and young children may be al increased risk from gadolinium staying in the body. • Some people with kidney problems who get gadolinium medicines can develop a condition with severe thickening of the skin, muscles and other organs in the body (nephrogenic systemic fibrosis). Your healthcare provider should screen you to see how well your kidneys are working before you receive DOTAREM. Do not receive DOTAREM if you have had a severe allergic reaction to DOTAREM. Before receiving DOTAREM, tell your healthcare provider about all your medical conditions, Including if you: • have had any MRI procedures in the past where you received a GBCA. Your healthcare provider may ask you for more information including the dates of these MRI procedures. • are pregnant or plan to become pregnant. It Is not known If DOTAREM can harm your unborn baby. Talk to your healthcare provider about the possible risks to an unborn baby if a GBCA such as DOTAREM is received during pregnancy. • have kidney problems, diabetes, or high blood pressure. • have had an allergic reaction to dyes (contrast agents) including GBCAs. What are possible side effects of DOTAREM? • See "What is the most important information I should know about DOTAREM?" • Allergic reactions. DOTAREM can cause allergic reactions that can sometimes be serious. Your healthcare provider will monitor you closely for symptoms of an allergic reaction. The most common side effects of DOTAREM Include: nausea, headache, pain, or cold feeling at the injection site, and rash. These are not all the possible side effects of DOTAREM. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about the safe and effective uses of DOTAREM. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. You can ask your healthcare provider for information about DOTAREM that is written for health professionals. What are the ingredients in DOTAREM? Active Ingredient: gadoterate meglumine Inactive ingredients: DOTA, water for injection Manufactured by: Catelent and Recipharm (vials) for Guerbet For more Information, go to - or call allalialls This Medication Guide has been approved by the U.S. Food and Drug Administration. Rev. 412018 EFTA00520773 SCHAFFER, SCHONHOLZ & DROSSMAN, LLP 315 West 57th Street - LL4 New York, NY 10019 Tel: Fax hi PAIIENNgiagg.Bablic,rcz%:" ; ';;; , ' tt‘le;;;t3.;;', Patient Name: Medical Record #: Date of Exam: Referring Dr.: Date of Birth: Age: Height: Weight: O Male O Female WARMNG:TtlaMig,§XSTENI:M.40N.atr.14i40.1fi.YS.ON • ,' I. • Certain implants, devices or objects may be hazardous and/or may interfere with your MRI procedure. 0 Do not enter the MRI exam room if you have questions or concern regarding an implant, device or object. k Consult the MRI Technologist BEFORE entering the MRI exam room. DO YOU.HAVE.ANY OF THE'FOALOWINGt `. - . . IMPORTANT INSTRUOTIONS ' - OYES ONO Injury to your eye involving metal OYES ONO My metallic fragment or foreign body OYES ONO Aneurysm clip(s) OYES ONO Cardiac pacemaker DYES ONO Implanted cardioverter defibrillator (ICD) OYES ONO Electronic implant or device OYES ONO Magnetically-activated implant or device OYES D NO Neurostimulation system OYES ONO Spinal cord stimulator OYES ONO Internal electrodes or wires OYES ONO Bone growth / bone fusion stimulator DYES ONO Cochlear, otologic or other ear implant DYES ONO Insulin or other infusion pump DYES • NO Implanted drug Infusion device OYES ONO Any type of prosthesis (eye, penile, etc.) OYES ONO Heart valve prosthesis OYES ONO Eyelid spring or wire OYES ONO Artificial or prosthetic limb DYES ONO Metallic stent, filter or coil OYES ONO Shunt (spinal or intraventricular) OYES ONO Vascular access port and/or catheter OYES ONO Radiation seeds or implants OYES ONO Swan-Ganz or thermodilution catheter OYES ONO Medication patch (Nicotine, Nitroglycerine, etc.) OYES ONO Wire mesh implant DYES O NO Tissue expander (breast or other) DYES ONO Surgical staples, clips or metallic sutures OYES ONO Joint replacement (hip, knee, etc.) OYES ONO Bone/joint pin, screw, nail, wire, plate, etc. OYES ONO IUD, diaphragm or pessary OYES ONO Other implant: Mark implant on the or C — • - - _ figure metal - below the inside of or t '' location on J -\ your l. ,r of body If any RIGHT Remove ALL including: - hearing - _ dentures cell phone - keys - eyeglasses - hair pins - jewelry - safety - money - credit cards, - pens - pocket - nail clipper - clothing - steel-toed - tools - all loose aids and and and pins clip knife with metallic I metallic and watch, and bank boots/shoes LEFT LEFT objects in the partial plates pagers barrettes Including body coins cards and metal fasteners and objects 1 dressing piercing magnetic metallic RIGHT room, jewelry strip cards threads OYES ONO Dentures or partial plates OYES O NO Tattoo or permanent makeup OYES ONO Body piercing jewelry O YES O NO Hearing aid (remove before entering exam room) OYES ONO Breathing problem or motion disorder OYES ONO Claustrophobia * Consult the MRI Technologist if you have any questions or concerns BEFORE you enter the exam Technologist Notes: * Aft patients •having MRI studies MUST wear hearing protection (ear. pitigs or earmuffs)...No exceptions. EFTA00520774 PREGNANCY and BREASTFEEDING STATUS * If a mother desires, she may refrain from breastfeeding for 24 hours and discard milk after gadolinium injections. Are you: Pregnant? K Yes K No Possibly Pregnant? 0 Yes O NO Breast Feeding? K Yes K No Date of Last Menstrual Period: SKINWARMIN(3,. .. . * MRI Radiofrequency has the potential to cause tissue heating. Precautions will be taken to avoid this. Alert the technologist Immediately if you notice any heating sensations during your MRI scan. PIERCINGS; COSMETIC IMPLANTS, TATTOOS ANDPERMANENT MAKEUP * A small number of patients have experienced transient skin irritation, swelling, bruising or heating sensations at the site of piercings, cosmetic implants, tattoos and permanent makeup in association with MR procedures. Individuals with these items should Inform the technologist so precautions can be taken. _MEDICAL HISTORY Why are you having this test done? What is the reason? List surgeries you have had and date of surgery: Where/What area is the problem? Body part involved? Do you have or ever had cancer? K Yes K No If yes: What Type — Where (body part) Which side (left/right/upper/lower)? When did your symptoms start? Describe the problem it is giving you. What type of treatment did you receive and when? Did you injure the area of interest? K Yes K No If yes, describe: Check all that are applicable to your symptoms: K Acute (present or a severe and intense degree) K Chronic (persisting a long time / constantly recurring) O Intermittent K Transient (lasts only a short time) O Primary issue K Secondary due to another issue List any tests you had at other facilities for this problem: Ex: Lab, X-Ray, Upper GI, BE, Ultrasound, MRI, CT Test — Date — Where List all medications you are taking and what they're for: Have you been In the hospital within the last week? O Yes K No If yes, describe below: Have you ever experienced any problem related to a previous MRI procedure or MRI contrast? K Yes K No DO YOU HAVE ANY OF THE FOLLOWING? TECHNOLOGIST NOTES K YES ONO Kidney disease or kidney Injury K YES ONO Kidney surgery, transplant, single kidney ❑YES ONO Kidney tumor or cancer ❑YES ONO Diabetes OYES K NO Are on dialysis ❑YES O NO Chemotherapy in the past 3 months OYES K NO Take medication for hypertension (follow local protocol) K YES ONO Past allergic reaction to gadolinium or Iodine contrast OYES ONO Asthma or allergy CONTRAST CONSENT Due to your medical history, or as requested by your physician, an injection of MRI gadolinium contrast may be necessary to aid the radiologist in evaluating your MRI scan. The Food and Drug Administration has approved this agent. A very small percentage of patients receiving gadolinium may develop a headache or experience mild nausea. Rarely, local Inflammation may occur at the Injection site. O I CONSENT to having Gadolinium contrast as needed. (Check box if you agree to contrast) O I DECLINE having a Gadolinium contrast injection at this time. (Check box if you disagree to contrast) I attest that the information on this form Is correct to the best of my knowledge. I have read and understand the contents of this form and had the opportunity to ask questions regarding the MR procedure I am about to undergo. I understand that emergency or follow-up care, if needed, is the direct financial responsibility of the patient receiving additional 3rd party services (ambulance transport to a hospital, 911 call, medical care, etc.). PatienliGuardian Signature: Date: FOR STAFF USE: Screening Performed By: O MR Technologist Staff Signature: O Nurse O Radiologist O Other: Print Name: EFTA00520775 SCHAFFER, SCHONHOLZ & DROSSMAN, LLP C Tax ID tt 13-198-5544 MRI PROCEDURES PRE-CERTIFICATION INFORMATION Most insurance companies require pre-certification for MRI examinations. Below, you will find the procedure codes your insurance carrier will need to pre- certify your MRI. Please note that it is the patient's responsibility to initiate the pre-certification process by calling the insurance carrier and notifying them of the procedure to be performed. Your insurance company pre-cert specialist may also request to speak with your Referring Physician during the pre- certification process. Should they have any additional questions, please have them contact our Billing Department at Ext. 17. Thank you. BREAST MRI - BILATERAL CPT-4 CODE DESCRIPTION FEE 77049 $ Z200 MRI BREAST - BILATERAL w/wo CONTRAST and 3D RECONSTRUCTION and ANALYSIS ON INDEPENDENT WORKSTATION BREAST MRI - UNILATERAL CPT-4 CODE DESCRIPTION FEE 77048 MRI BREAST - UNILAT w/wo CONTRAST and 3D RECONSTRUCTION and ANALYSIS ON INDEPENDENT WORKSTATION $ 2,100 • MRI GUIDED BREAST BIOPSY CPT-4 CODE DESCRIPTION FEE 19085 MRI GUIDED BIOPSY, BREAST, WITH OR WITHOUT PLACEMENT OF CUP AND IMAGING OF THE BIOPSY SPECIMEN, PERCUTANEOUS, FIRST LESION $ 3,275 G0206 DIGITAL MAMMOGRAPHY/UNILATERAL 325 TOTAL FEE: $ 3,600 19086 MRI GUIDED BIOPSY, BREAST, + EACH ADDITIONAL SITE WITH OR WITHOUT alp PLACEMENT $ 3,275 NOTE: Breast biopsies require that we send the tissue specimen obtained during the procedure to a pathologist for microscopic examination and reporting. The specimen obtained will be sent to Mount Sinai Pathology Associates or to the University of Pennsylvania Surgical Pathology Department. New York State Law (Section 394-E) requires that clinical laboratories bill patients directly. The lab processing your specimen(s) will bill you separately for their services. If you have any questions regarding the laboratory billing, please contact: Mt Sinai Pathology Associates: 1-800-542-5760 UCKlatei 05/33/19 University of Pennsylvania Pathology: EFTA00520776