Get General Radiology Exam Order Form - Choa 2020-2025

Filling out the General Radiology Exam Order Form - Choa online is a crucial step in ensuring timely and accurate medical imaging. This guide will provide you with detailed instructions to complete the form effectively and efficiently.

Follow the steps to fill out the General Radiology Exam Order Form - Choa online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the patient's full legal name and date of birth in the designated fields. Ensure that this information is accurate, as it will be used to identify the patient.
3. Fill in the home phone number, and the full address of the patient, including city, state, and zip code. All areas marked in bold are required for processing.
4. Enter the guarantor's email address and cell phone number for communication purposes.
5. Select the insurance or Medicaid plan and input the policy and group numbers. Include the authorization number, ensuring you also fax a copy of the insurance card, front and back.
6. Detail the reason for the exam by filling in signs, symptoms, or chief complaints in the appropriate section.
7. The ordering physician is required to provide their signature in the indicated area, along with their printed name, practice phone number, and the date the form is signed.
8. If applicable, include the primary care physician's name and fax number, if different from the ordering physician.
9. Mark any special instructions as needed, including whether to send a CD or films with the patient.
10. Select the required radiology exams by checking the appropriate boxes and specifying any additional comments or order details.
11. Review all entered information for accuracy and completeness, saving changes as necessary.
12. Once all fields are completed, you can download, print, or share the form as needed.

Complete your documents online to ensure timely processing and care.