Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to access the form and open it in your preferred PDF editor.
2. In the 'Date of Order' section, enter the current date to indicate when the order is being placed.
3. Fill in the appointment details by providing the 'Appointment Date' and 'Appointment Time.' You will need to specify whether the appointment is in the AM or PM.
4. Complete the 'Patient Information' section, including the patient's name, date of birth, and contact telephone numbers. Mark the patient's gender as either 'M' or 'F.'
5. Indicate any patient needs in the 'Patient Needs' section, such as if transportation or an interpreter is required.
6. In the 'Patient History/Diagnosis' section, provide a clear description of the patient's medical history and diagnosis relevant to the imaging request.
7. Select the relevant x-ray or MRI procedures needed by checking the appropriate boxes in the 'X-ray Procedure Information' section. Be sure to indicate left or right side if applicable.
8. Under 'Insurance Information,' provide details of the patient’s insurance coverage. Check the appropriate options for how the appointment will be scheduled and fill in carrier names if applicable.
9. Complete the 'Image Delivery Preference' if applicable, selecting how the images should be delivered and providing any pertinent details like the date of injury or claim number.
10. In the 'Referring Physician' section, enter the physician’s name, phone, fax, and ensure that the physician's signature is included. Also fill in the clinic name.
11. After filling out all sections of the form accurately, save your changes, and you may choose to download, print, or share the completed document as necessary.

Take the next step in your healthcare journey by completing the Northwest-MRI-X-Ray-Referral-Form-1pdf online today.