i3 USINESS RECOMJS AFFIDAVIT
`
`_ ME,
`BEFORE
`personally
`authority,
`undersigned
`g ifu‘ld 121
`[31631019
`, who, being by me duly sworn, deposed as follows:
`“My name is
`ECU”) citra Webb
`.
`I am over 18 years 01‘ ago, of sound
`
`appeared
`
`the
`
`mind. capable of making this affidavit, and personally acquaintcd with the facts herein stated:
`
`I am the custodian of the medical records of MRI Centers of Texas. Attached hereto are
`
`7/31/1967. These said 3 pages 01 records are kept by MRI Centers 01 [exas in the regular
`
`course of business. and it was the regular course of business of MRI Centers of Texas for an
`
`employee or representative of MRI Cenlers of Texas with knowledge of the act‘ event, condition,
`
`opinion. or diagnosis recorded to make the record or to transmit
`
`information thereof to be
`
`included in such record; and thc rccord was made at or near the time or reasonably soon
`
`thereafter. The records attached hereto are the originals or
`
`lica’tes 01' the originals."
`
`SWORN TO AND SUBSCRIBED before meon the \ é day ol'_\ii )1 iké' _,
`
`
`
`
`
`Notary Public. State of Texas
`
`
`
`
`
`

`

`
`
`
`WK“
`M RI
`,Centers OfTexas
`MRI - X—Ray 0 CT
`
`Report by:
`TexRadGroup
`
`Radiologists of Texas
`
`1414 South Loop West, Suite 120, Houston, TX 77054
`(844) MRI-Of-TX 0 Fax (832) 956-1802
`
`Date of Exam: 10/31/2016 12:54:40 PM
`Patient NamezHUFFMAN, MICHELLE
`Date of Birth: 7/31/1967
`Med. Rec. #: 002265
`
`Referring Dr.: DR. SHANE SIGG
`Radiologist: DR NICHOLAS IWASKO
`Date of Injury: 9/29/2016
`Diagnostic Code:
`
`MRI CERVICAL SPINE
`
`CLINICAL HISTORY: Neck pain with history of motor vehicle accident.
`
`TECHNIQUE: Sagittal T1, T2, and STIR, and axial T2-weighted sequences were acquired through
`
`the cervical spine.
`
`FINDINGS: No cerebellar tonsillar herniation is appreciated. There are no intramedullary spinal
`cord lesions.
`
`C2-3: A broad disc protrusion/herniation is present measuring 2 mm to the right and 1 mm to
`the left with mild right neural foraminal narrowing. The disc herniation extrudes 2 mm
`superiorly and 1.5 m inferiorly. There is no significant thecal sac stenosis. The left neural
`foramen is patent.
`
`C3-4: A broad 2-3 mm disc protrusion/herniation is present with borderline thecal sac stenosis.
`There is moderate-to-severe right neural foraminal narrowing and moderate left neural
`foraminal narrowing. Uncinate hypertrophy is appreciated.
`
`C4-5: There is a broad disc protrusion/herniation measuring 3 mm to the right and 2 mm
`centrally and to the left with borderline thecal sac stenosis. There is severe right and moderate
`left neural foraminal narrowing with uncinate hypertrophy.
`
`C5-6: A broad 3 mm osteophyte disc protrusion complex is present. There is borderline thecal
`sac stenosis. Severe left and moderate-to-severe right neural foraminal narrowing with
`
`uncinate hypertrophy are appreciated.
`
`C6-7: There is a fusion at this level which appears to be congenital. Mild bilateral neural
`foraminal narrowing is present with uncinate hypertrophy. There is no intervertebral disc and
`
`no thecal sac stenosis is present.
`
`

`

`
`M RI
`
`Centers Of Texas
`'a
`MR1. X-Ray . CT
`
`Report by:
`
`TexRad Group
`
`Radiologists of Texas
`
`1414 South Loop West, Suite 120, Houston, TX 77054
`
`(844) MRI-Of—Tx :- Fax (832) 956-1802
`
`Date of Exam: 10/31/2016 12:54:40 PM
`Patient Name: HUFFMAN, MICHELLE
`Date of Birth: 7/31/1967
`Med. Rec. #:
`002265
`EXAM: MRI CERVICAL SPINE
`
`PAGE TWO
`
`Referring Dr.: DR. SHANE SIGG
`Radiologist: DR NICHOLAS lWASKO
`Date of Injury: 9/29/2016
`Diagnostic Code:
`
`C7-T1: A broad disc protrusion/herniation is appreciated measuring 2 mm to the right and 1
`mm centrally and to the left with mild right neural foraminal narrowing with uncinate
`hypertrophy. There is no thecal sac stenosis or left neural foraminal encroachment.
`
`A bone lesion is present within C5. It is decreased in signal on T1 and increased in signal on T2
`
`and STIR images. It has lobular margins. It measures 7 mm.
`
`IMPRESSION:
`
`1. C2-3: Broad disc protrusion/herniation measuring 2 mm to the right and 1 mm to the left
`with mild right neural foraminal narrowing. The disc herniation extrudes 2 mm superiorly and
`1.5 mm inferiorly.
`
`2. C3-4: Broad 2-3 mm disc protrusion/herniation with borderline thecal sac stenosis,
`moderate-to-severe right neural foraminal narrowing and moderate neural foraminal
`narrowing. The right C4 nerve root is likely impinged upon.
`
`3. C4-5: Broad disc protrusion/herniation measuring 3 mm to the right and 2 mm centrally and
`to the left with severe right and moderate left neural foraminal narrowing, as well as borderline
`thecal sac stenosis. The right C5 nerve root is impinged upon.
`
`4. C5-6: Broad 3 mm osteophyte disc protrusion complex with borderline thecal sac stenosis,
`severe left neural foraminal narrowing, and moderate-to-severe right neural foraminal
`narrowing. The bilateral C6 nerve roots are impinged upon, particularly on the left.
`
`5. C6-7: A congenital fusion is present at this level with mild bilateral neural foraminal
`
`narrowing.
`
`6. C7-T1: Broad disc protrusion/herniation measuring 2 mm to the right and 1 mm centrally
`and to the left with mild right neural foraminal narrowing.
`
`

`

`
`M RI
`
`Centers Of Texas
`MR1. X—Ray . CT
`
`Report by:
`
`TexRadGroup
`
`Radiologists of Texas
`
`1414 South Loop West, Suite 120, Houston, TX 77054
`
`(844) MRl-Of—TX 0 Fax (832) 956-1802
`
`Date of Exam: 10/31/2016 12:54:40 PM
`
`Referring Dr.: DR. SHANE SIGG
`
`Patient Name: HUFFMAN, MICHELLE
`Date of Birth: 7/31/1967
`
`Radiologist: DR NICHOLAS IWASKO
`Date of Injury: 9/29/2016
`
`002265
`Med. Rec. #:
`EXAM: MRI CERVICAL SPINE
`
`PAGE THREE
`
`Diagnostic Code:
`
`7. 7 mm bone lesion within the C5 vertebral body with lobular margins. Its signal characteristics
`
`are not consistent with a typical benign hemangioma. If the patient has a history of a prior
`malignancy which can cause bone metastases, the lesion should be considered suspicious. If
`this is not the case, it would be helpful to obtain a CT to determine if the lesion is an atypical
`hemangioma with low fat content, which would explain its unusual signal characteristics on this
`exam.
`
`Electronically signed:
`
`_.r/
`
`._.
`
`ti .1 22.2.; _ 2....-.
`
`NICHOLAS G. IWASKO, M.D.
`
`Board Certified Musculoskeletal Radiologist
`ETzdd
`
`Report content or billing questions? Call TexRadGroup @ Dallas Radiology: 866-931-3811
`
`

`

` (Centers Of Texas
`
`sq,
`
`032—955—1500
`
`AUTHORIZATION TO DISCLOSE PATIENT HEALTH INFORMATION
`
`
`Patient Name: _HUFFMAN MICHELLF
`_v
`Date of Birth: Q7Z31g1967
`
`Date oflnjury: 09(29(2_01_6
`
`Date of Request:
`
`105311201§
`
`As required by HIPAA privacy regulations, protected health information may not be used or disclosed to any
`third party without patient authorization.
`I hereby authorize MRI Centers Of Texas and its employees to disclose my protected health information to the
`lollowing persons, healthcare provider, or business associate:
`Attorney Name: JIM ADLER
`Phone: (214)320-1111
`Qo_ctor Name:
`SIGGl SHANE Phone: 7137820082
`
`Fax: (214)220-3233
`Fax: (214l220—3233
`
`I authorize MRI Centers OfTexas to transmit my medical records electronically. If they
`MEDICALfingRDS FAX:
`are received by another party in error, | absolve MRI Centers of Texas ofany and all liability relating to such
`submission of said records This authorization is good seven years from today's date.
`
`I hereby authorize MRI Centers OfTexas to disclose and/or re—disclose my individually identifiable health
`information to an attorney of their choosing as described below, which may include information concerning
`communicable diseases such as HIV/AIDS, mental illness, chemical or alcohol dependency, laboratory test
`results, medical history, treatment or any other such related information. [further understand that if the
`recipient attorney authorized to receive the information is not a covered entity, the released information
`may no longer be protected by federal and state privacy regulations.
`This authorization is valid until the
`earlier of the occurence of the death of the individual; the individual reaching the age of majority;
`or 7 years passed or permission is withdrawn.This release authority applies to any information governed by
`the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 U.S.C. 1320d and 45 C.FrR.160-164.
`The authority given to MRI Centers Of Texas will expire according to the applicable federal or state laws,
`and I further understand that i can revoke this HIPAA Release in writing at any time by delivering said revocation
`to my health-care provider. There are no exceptions to my right to revoke this HIPAA Release. A photocopy of
`this document Will act as an original for all intents and purposes.
`I hereby authorize the disclosure of my individually identifiable health information and allow MRI Centers of Texas
`to release the same to an attorney of their choosing in the event my representing attorney~
`
`withdrawjfimirgprcientatiog.
`
`I understand I have the right to:
`Rcvoke this authorization by sending written notice to this office and that revocation will not affect this
`office previous reliance on the uses or disclosure pursuant to this authorization
`Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization,
`and as a result of this authorization.
`
`Inspect a copy of the patient health information being used or disclosed under federal law.
`Refuse to sign this authorization.
`Restrict what is disclosed with this authorization.
`
`I also understand that if I do not sign this document, it will not condition my treatment, payment, and
`enrollment in a health plan, or eligibility [or match“ whether or -
`t I rovido authorization to use or disclose
`
`protected patient health information
`
`/S|Hl13lu orPatlen I or F‘
`uthonted Representative
`
`Date
`
`I provide MRI Centers OfTexas by way of signature, the authorization and consent to use and disclose my protected healthcare
`
`information for the purposes of treatment, payment and healthcare operations as described in the privacy notice.
`
`10(31[2016
`
`Date:
`
`Authorized facility Signature:
`
`Mngenters Of Texas
`
`-4 Date: l0131z2016
`
`

`

`as.
`
`M RI
`Centers Of Texas
`1332-9564800
`
`Patient History and Screening Form
`(Ifyou are here for X-Ray, only fill in Section II)
`Please read and answer each question carefully as it pertains to you and the test you are having.
`
`‘1' Section I (MRI Patients Only)
`Cardiac (Heart) Pacemaker?
`Heart Disease or Arrthythmias?
`Other Heart Surgery, stents or valves?
`Neu ro-Stimulator (tens unit) other Implanted
`Electrodes, Pumps or Devices?
`Brain Surgery or Aneurysm Clip?
`Other Vascular Surgery?
`War Injury or Gunshot Wound?
`Metal Fragments in Eye or other body parts
`that had to be removed?
`
`Eye Surgery or Prosthetic (ie. Buckel, Cataract Implants?)
`Joint and Limb Replacement Metal Rod, Pin, Screw,
`or other Orthopedic Device?
`Middle Ear or Orbital Prosthesis?
`
`Hearing Aid or Dentures?
`Currently Wearing Medication/Nicotine Patch?
`‘Any Renal/Kidney Failure or Disease?
`Asthma or Other Lung Disease?
`
`High Blood Pressure?
`Have you ever had Cancer or Radiation Therapy?
`lfso, When?_______
`Tattoos, Body Piercings, or Permanent Make--up?
`List of Previous Surgeries
`
`Yes
`__
`__
`__
`
`_
`__
`_
`_
`
`__
`
`X
`__
`X
`
`lX1><l><l><l><l><l><lx§
`
`lXP‘leXleP‘l
`
`ow
`
`—
`,5jd/HL481—EJ%E
`
`HAVE YOU HAD ANY ALLERGIC REACTION TO CONTRAST INJECTIONS FOR MRI 0R CT SCAN YES
`
`Section II Female Patients (Ages 12-55)
`Is there any possibility of pregnancy?
`Do you have an IUD?
`Are you breastfeeding?
`(’2 ’ Q (2Q é
`Date of last menstrual cycle?
`I understand that radiation exposure can be harmful to a fetus and understand the risk involved ifl am pregnant at
`
`YES
`_
`_
`_
`
`No
`A
`D1.
`
`the time.
`Please sign.
`
`a
`
`Date:
`
`lglggjgpls
`
`llllllllllllllllllllllllllllllllllllllllllllllllllllll
`
`HUFFMAN, meme
`
`

`

`4...
`
`Wnters OfTexas
`
`832-956-1800
`
`Iii-3
`
`10/31/2016
`
`Location:
`
`HOUSTON
`
`IMAGING: MRI CERVICAL
`
`Study:
`
`HUFFMAN MICHELLE
`
`,
`
`, Have you been seen before at our office?
`
`LI Y My
`
`5&0 ( MASUS POQ
`
`l
`
`Referring Physician:
`
`SIGGl SHANE
`
`’7 State: Tffl’
`
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`
`:_
`
`:7 "MN/6
`
`__flj31f1967
`
`Age:
`
`#QQ—YEAR-OLD
`_
`
`Cl Slip/Fall
`
`In Insurance
`
`[3 Cash
`
`Other: ______
`
`_Q9fi2912016
`
`SSN:
`
`Home Phone:
`
`(281) 793-5146
`
`d (2
`
`Weight:
`
`{15 a
`
`_.w Other Phone:
`
`l
`
`I
`
`-
`
`Spouse or Parent Name:
`
`Reading Rad.
`
`IWASKO, NICK
`
`INSURANCE COMPANY AND/OR ATTORNEY INFORMATION (please provide both if applicable)
`
`
`
`Attorney Name:
`
`JIM ADLER
`
`
`__
`
`Phone:
`
`(214)320-1111
`
`Fax:
`
`(214)220—3233
`
`State: _-
`
`Zip:
`
`Policy #2
`
`
`
`
`_
`__
`
`W/C Pre‘Auth #2
`
`
`_ _
`
`
`
`
`
`
`
`
`
` State: ___ Zip:City: __ __ ___
`leas
`sign below to acknowledge you have read and understand this screening forrn.
`
`47%; _I4/
`Witness
`
`
`Patient’s Signatu
`r Parent’s (if minor]
`
`
`
`Date:
`IIIIIIliilillllillllliililillllllllillliillllillillllllll
`
`10(31Z2016
`
`HUFFMAN, MICHELLE
`
`Date:
`1_fl31(2__16_
`Date.L/A We.4./___ij
`
`

`

`551“
`Mm
`Centers; 011'?(1an
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`Central Scheduhng Phone: (8321 3%1800Fax: (832)956—1802
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`IV
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`VIJUIIIH
`
`ELITEFAMILYCHIROPRACTIC
`1349 PEARIAND PKWY#107
`Peaxland,TX77581
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`P.
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`M13249
`WWW
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`Appointments Time & Day :
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`DoctorsSignatur95k%-1 l_%m ‘0 “)4\ “.9
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`Phone? 713-782-0082
`
`"ax: 837-~'~" r3-7543
`
`W” Please notate in the patient's SOAP note the reason for
`the MRI, Orthopedic, or Neurological referral when indicated.
`
`