Patient Consent
Appointment Policies & Communication Consent
Thank you for choosing Sacred Center Sonography. Our goal is to provide every patient with a relaxed, personalized, and unrushed experience. To help us provide the highest level of care while respecting everyone's scheduled appointment time, please review the following policies.
Appointment Arrival
Please arrive 15 minutes before your scheduled appointment. This allows time for check-in and helps ensure your appointment begins on time.
Late Arrivals
If you are running late, please call us as soon as possible. We understand that unexpected delays happen, and we will always do our best to accommodate you whenever possible.
Patients arriving more than 10 minutes after their scheduled appointment time may need to be rescheduled to avoid disrupting the schedule for other patients. Communication is important, and whenever possible we will work with you to find the best solution.
Cancellations, Rescheduling & Refunds
Appointments may be modified or rescheduled up to 48 hours before the scheduled appointment time.
If you wish to cancel your appointment and receive a full refund, your cancellation request must be received at least 48 hours before your scheduled appointment. Refunds will be issued to the original method of payment.
Cancellations made less than 48 hours before the scheduled appointment are not eligible for a refund.
Cancellations made within 24 hours of the scheduled appointment will be subject to a $30 cancellation fee.
We understand that unexpected situations and emergencies can occur. If something unavoidable prevents you from keeping your appointment, please contact us as soon as possible. We value open communication and will always do our best to work with you whenever possible.
No-Show Policy
Patients who do not arrive for their scheduled appointment and do not notify us in advance will be considered a no-show. Because appointment times are reserved specifically for each patient, 100% of the appointment fee will be retained.
Once services have been provided, no refunds will be issued.
Communication Consent
By scheduling an appointment with Sacred Center Sonography, you consent to receive communications related to your appointments and care by phone call, text message, and email. These communications may include appointment confirmations, reminders, scheduling updates, and other important information regarding your visit.
Standard message and data rates may apply depending on your mobile carrier.
We value open communication and are committed to providing exceptional care. If you have questions or concerns before your appointment, please don't hesitate to contact us—we're here to help.
Patient Consent for Use and Disclosure of Protected Health Information and Pre-Exam Acknowledgement
I hereby give my consent for Sacred Center Sonography, LLC and its partnering physician group to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
The practice reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy practice may be obtained by forwarding a written request to 1151 Dove St, Suite 280, Newport Beach, CA 92660.
With this consent, we may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care. No test results, however, will be left on voicemail or with any other person without a specific request by me to do so.
With this consent, we may mail to home or other alternative location any items that assist the practice in carrying out TPO such as appointment reminder cards and patient statements.
I have the right to request that the practice restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to the use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.
With regards to my examination, I understand that I may be required to remove certain garments and wear a hospital gown. I also understand that the technologist performing my exam must maintain a close proximity to me during the examination and must engage in contact with the area being examined to satisfy the logistical requirements for successful completion of the exam. I understand that this is necessary and will be executed in a strictly professional manner with respect to my dignity and privacy. I waive any liability to the practice should I suddenly find objection to this during my examination.
DISCLOSURE OF HEALTH INFORMATION
I hereby give my consent for Sacred Center Sonography and its contracted interpreting radiologist(s) to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO).
Sacred Center Sonography may contact me by text message, phone call, voicemail, or email regarding appointment reminders, scheduling, payment matters, and information related to my care. Ultrasound results and other protected health information will not be communicated by voicemail, text message, or email.
I have the right to request that Sacred Center Sonography restrict how my protected health information is used or disclosed to carry out treatment, payment, and health care operations. The practice is not required to agree to my requested restrictions; however, if it does, it will honor that agreement. I may revoke this consent in writing, except to the extent that the practice has already relied upon my prior consent.
CLINICAL ACKNOWLEDGMENT
I understand that I may be required to remove or adjust clothing as needed for my ultrasound examination and that appropriate draping will be provided. The sonographer performing my examination must maintain close proximity and physical contact with the area being examined in order to properly perform the ultrasound examination. This examination will be conducted professionally and with respect for patient dignity and privacy.
FINANCIAL ACKNOWLEDGMENT
I acknowledge that Sacred Center Sonography is a self-pay practice. Payment in full is required at the time of booking to reserve my appointment. I understand that insurance is not billed by Sacred Center Sonography, and I am responsible for all charges associated with my appointment. Collecting payment in advance allows our team to focus entirely on providing a relaxed, personalized ultrasound experience during my visit, without interruptions for financial transactions at the time of my appointment.
HIPAA Notice of Privacy Practices
Sacred Center Sonography
Effective Date: August 1, 2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, HOW YOU MAY ACCESS THIS INFORMATION, AND YOUR PRIVACY RIGHTS. PLEASE REVIEW IT CAREFULLY.
Our Commitment to Your Privacy
At Sacred Center Sonography, we understand that your health information is personal. We are committed to protecting the privacy and security of your protected health information (PHI). We create and maintain medical records, including electronic records, to provide quality care, document the services you receive, and comply with applicable federal and state laws.
We are required by law to:
• Protect the privacy of your protected health information.
• Provide you with this Notice of Privacy Practices.
• Follow the privacy practices described in this notice.
How We May Use and Disclose Your Health Information
Treatment
We may use and disclose your health information to provide your ultrasound services, coordinate your care, communicate with your referring healthcare provider, and assist with any necessary follow-up care.
Payment
Sacred Center Sonography is a self-pay practice. We may use and disclose your health information as necessary to process payments, provide receipts, or provide documentation that you request for reimbursement or other appropriate purposes.
Healthcare Operations
We may use and disclose your health information to operate our practice, improve the quality of our services, perform quality assurance activities, maintain medical records, train staff, and comply with legal and regulatory requirements.
As Required by Law
We may use or disclose your health information whenever required or permitted by applicable federal, state, or local law.
Public Health and Safety
We may disclose health information when permitted or required to protect public health, report certain diseases or injuries, respond to government agencies, or help prevent a serious threat to your health or the health and safety of others.
Legal Proceedings and Law Enforcement
We may disclose health information in response to court orders, subpoenas, lawful law enforcement requests, workers' compensation claims, or other legal processes when permitted or required by law.
Your Privacy Rights
You have the right to:
• Request to inspect or receive a copy of your medical records.
• Request corrections if you believe your medical information is inaccurate or incomplete.
• Request restrictions on certain uses or disclosures of your health information. While we will consider all reasonable requests, we are not always required to agree.
• Request that we communicate with you in a particular way or at a particular location whenever reasonably possible.
• Request an accounting of certain disclosures of your protected health information.
• Receive a paper or electronic copy of this Notice of Privacy Practices at any time.
Some requests must be submitted in writing, as required by applicable law.
Changes to This Notice
Sacred Center Sonography reserves the right to revise this Notice of Privacy Practices at any time. Any revisions will apply to both current and previously created medical records. The most current version of this notice will always be available upon request and through our website.
Questions, Concerns, or Privacy Complaints
If you have questions about this notice or believe your privacy rights have been violated, please contact Sacred Center Sonography using the contact information available on our website.
You also have the right to file a complaint with the U.S. Department of Health and Human Services. Filing a complaint will not affect your care or result in retaliation.
Other Uses of Health Information
Any use or disclosure of your protected health information not described in this notice will only be made with your written authorization when required by law. You may revoke your authorization in writing at any time; however, we cannot take back disclosures that have already been made in reliance on your authorization, and we are required by law to retain records of the care we have provided.