FREE MRI REVIEW
For a limited time, any patient in our local area, Southwest GA (or close enough to consider visiting our office for an appointment) can submit a recent spinal MRI for a free review for no charge.
Your MRI will be reviewed, and then the impressions can be discussed in a follow up phone call.
For any person interested in this offer, the instructions below must be followed:
1) The form below must be filled out and sent in with the images you want reviewed. Sometimes patients will submit an MRI report, which is not the same as viewing the images. The difference is like that between reading someone else’s description of a picture versus seeing the picture yourself.
2) Any patient submitting films for this review must understand that, unless they make an official appointment with me, that no doctor-patient relationship has been established.
3) This offer is for a limited time only, and can be discontinued at any time, and we will do our best to get back to you with our impressions in a timely manner.
4) Most imaging studies these days come on a disc, but occasionally, films are still used. If you want the images you submit to be returned to you, you will need to either come by the office and pick them up yourself, or provide an envelope with adequate postage to return the disc or films back to you.
5) If a signed agreement is not included with the films or discs submitted, the images with be returned without a review if return envelope and postage have been supplied, or if not, the images will be destroyed.
6) For the actual telephone report, the anatomy could be better explained if the patient has access to a computer with an internet connection. If a computer is not available, we will still make our description as detailed as possible to help you understand your condition.
SECOND OPINION MRI REVIEW AGREEMENT
(to be signed by the person whose images will be submitted)
I, the person who will sign below, agree to the following:
RELEASE OF LIABILITY
I understand that a doctor-patient relationship is not being established by submitting the films for Dr. Wolgin to review, a service which is being provided for no charge. I fully release Dr. Wolgin and any of his partners and employees from any liabililty that might arise from either doctor reviewing these images, either directly or indirectly. I understand that, unless I become a patient by making an appointment and visiting with either doctor in person for a full history and exam, that Dr. Wolgin will not be making any official treatment decisions on my case, nor will either doctor be prescribing any pain medications.
However, I also understand that I have an option to become a patient of his, but for details in this regard, I would have to speak with the appointment desk at Orthopaedic Associates, 229-883-4707.
DISCLOSURE OF MEDICAL INFORMATION
Dr. Wolgin takes seriously the privacy of my medical records and personal information. Accordingly, he and the staff of Orthopaedic Associates have taken all reasonable restrictions necessary to protect my confidentiality in accordance with all applicable laws. By sending my studies to Dr. Wolgin for review, I acknowledge I am sending medical information to him, and that I may discuss some aspects of my condition with him when he reviews the study impressions with me.
In addition, I authorize Dr. Wolgin and his partners and/or employees to access, review, analyze, discuss and copy my medical and personal information as may be necessary to provide the second opinion I request. There is a possibility that my images may be used for teaching or educational purposes, but there will be no information or aspect of my images that could be used to identify me personally.
The opinion of Dr. Wolgin will be conveyed to me in a phone call. Most often, my condition can be illustrated by other images from the website, drwolgin.com or from other sites on the internet. If I want to review my pictures with the doctor in person, I would need to make an official appointment to see the doctor in the office.
RELIANCE ON SECOND OPINION
I acknowledge and agree that the second opinion from Dr. Wolgin is exclusively for the purposes of obtaining a second opinion, and does not in any form, shape or fashion constitute a diagnosis, medical advice, treatment, medical care or establish any doctor-patient relationship with Dr. Wolgin. However, I also understand that I am free to make an appointment and establish such a relationship. Until such appointment is made, the review of the MRI is for Dr. Wolgin to give his impression only.
Further, I understand that, until or unless I become a patient of Dr. Wolgin, my current treating physician will remain at all times solely responsible for my diagnosis, care, and treatment. I understand I am certainly free to discuss with your current physician the opinions of Dr. Wolgin from your study review.
NO FEES ARE DUE FOR THIS REVIEW
STORAGE OF MEDICAL INFORMATION
I understand that, following Dr. Wolgin’s review of my studies, my images will be returned to me in the stamped self-addressed envelope I have provided. If I decide I might like to make an appointment to see Dr. Wolgin as a patient myself, I understand that Dr. Wolgin, through his office at Orthopaedic Associates, will hold on to the films for a period of no more than 60 days. After that time, if an appointment has not been made, and if a stamped, self addressed envelope has not been provided, I understand that Orthopaedic Associates will destroy the image files. I also understand that Dr. Wolgin is not responsible for maintaining any record storage functions for my studies outside of that 60 day period. If I do become a patient of Dr. Wolgin or Orthopaedic Associates, my records will be archived as they are for all our other patients in the routine fashion of our office. Additionally, I understand that Dr. Wolgin and his staff are not responsible for any items that are lost or stolen while being shipped either to or from his office.
Signature of person submitting images
City: _______________________ State: ________ Zip: ____________
Phone contact information: ( ) ___________________ ( ) Home ( ) Cell
Best time to call: __________________________ ( ) AM ( ) PM
Insurance carrier: ___________________________________________________
If the person submitting the images is calling/submitting for anyone other than themselves, they need to submit a copy of the legal document called “Power of Attorney for Health Care” in order to give permission to Dr. Wolgin to discuss confidential health information for the person to whom the images pertain.