Notice
Release
History

According to the Legislature of Texas, Subchapter B, Chapter 86, Health and Safety Code, Section 86.013

If your mammogram demonstrates that you have dense breast tissue, which could hide abnormalities, and you have other risk factors for breast cancer that have been identified, you might benefit from supplemental screening test that may be suggested by your ordering physician.

Dense breast tissue, in and of itself, is a relatively common condition. Therefore, this information is not provided to cause undue concern, but rather to raise your awareness and to promote discussion with your physician regarding the presence of other risk factors, in addition to dense breast tissue.

A report of your mammography results will be sent to you and your physician. You should contact your physician if you have any questions or concerns regarding Henda’s Law or your mammography report.

Notice for Henda's Law

According to the Legislature of Texas, Subchapter B, Chapter 86, Health and Safety Code, Section 86.013, I,

First Name

Last Name

, have received notice of the Henda’s Law.

Patient Signature

Date

Signature of person providing notice

Date

HIPPA COMPLIANT

Request for Relese of Mammogram(s) and Reports

Patient Name

MR#

Previous or Maiden Name

Date of Birth

Telephone Number

Last 4 of Your Social Security Number

I hereby authorize St. Joseph Women's Imaging Center to release my mammogram(s) and reports to:

Name of Facility

Phone Number

Address

City

State

Postal / Zip Code *

Authorization

Choose the type of transfer, permanent or temporary

Choose your delivery method

I hereby authorize:

Name of Facility

Phone Number

Address

City

State

Postal / Zip Code *

To release my mammogram(s) and reports to:

St. Joseph Health

Women's Imaging Center

2801 Franciscan Drive

Bryan, Texas 77802

Authorization

Reason for request: The continuation of patient care at this facility.

Type of media preferred

Please notify us if you do not have the requested studies.

PHONE: 979-776-2480 FAX: 979-704-3336

Patient Signature

Date

Unauthorized interception or use of this fax could be a violation of Federal and State law. If you have received this information in error, please notify the sender immediately. This fax may contain confidential information belonging to the sender and may be used only for the purpose for which it was requested or intended. You are responsible for securing any confidential information.

This fax may contain healthcare information. Permission to use or disclose this information has been granted either by law or the patient. Further use or disclosure without additional patient authorization or as otherwise permitted by law is prohibited.

HIPPA COMPLIANT

Mammography History Form

Note: If there is deodorant or powder on your breast or on your underarms, please remove it before you have your exam. Ask the technologist for help if you need it.

Name

Age

Telephone Number

Today's Date

Referring Physician

Date of Birth

1. Have you ever had a mammogram?

If yes, where & when?

2. Do you have implants?

3. Is this mammogram routine?

If no, why?

4. Have you had breast cancer?

If yes, at what age was it found?

5. Has anyone in your family ever had breast cancer?

If yes, at what age was it found?

5a. Relationship to family member who had breast cancer

6. Do you have a family history of other cancer?

If yes, specify

7. Are you pregnant?

Date of last menstrual period

Age at first period

8. Have you had a hysterectomy?

If yes, were your ovaries removed?

9. Have you had a child?

Your age when your first child was born

Number of pregnancies

Number of births

10. Do you, or have you used hormones (Estrogen, Premarin, Provera, Tamoxifen)?

If yes, which type?

How long?

Still using?

Stopped when?

11. Have you breastfed within the past 3 months?

12. Have you had a weight change of more than 10 pounds in the past 3 months?

13. Have you ever had trauma to your breast serious enough to cause black and blue marks?

If yes, when?

Signature

14. Email *

15. How will you like to be contacted?

HIPPA COMPLIANT