Get Uchealth Radiology Imaging Request Form
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How to fill out the UCHealth Radiology Imaging Request Form online
Filling out the UCHealth Radiology Imaging Request Form online is a straightforward process that requires attention to detail. This guide will provide you with step-by-step instructions to ensure that your imaging request is completed accurately and submitted efficiently.
Follow the steps to complete the form with ease.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the patient information in the specified fields, including the patient's name, date of birth, gender, address, city, state, zip code, and phone number.
- Fill in the insurance information with the member/provider services phone number, insurance provider, member ID, and group ID.
- Select the imaging order by checking the appropriate boxes for CT, MR, Nuclear Medicine, XRAY/Fluoro, Ultrasound, PET/CT Scan, or Other procedures.
- Indicate whether the procedure requires contrast by checking the relevant options: 'With Contrast', 'W/WO Contrast', or 'W/O Contrast'. If the patient has an allergy to contrast, please mark that option as well.
- Input the relevant diagnosis codes for the patient's condition and specify laterality by selecting left, right, or bilateral.
- Provide signs, symptoms, and clinical suspicion information, confirming whether the patient is claustrophobic and selecting any sedation options as necessary.
- Complete the referring provider information including the last name, first name, NPI, and contact details.
- Ensure that the provider’s signature and date are recorded at the bottom of the form.
- Select the appropriate imaging facility from the options provided: Metro Denver, North Region, South Region, or Boulder Sports Med.
- After completing the form, save your changes, and then download, print, or share the document as needed.
Complete your UCHealth Radiology Imaging Request Form online today to ensure timely processing.
A radiology request is a documented appeal for imaging services, allowing healthcare professionals to obtain necessary diagnostic images. This request is usually initiated by a physician who identifies the need for specific imaging studies. Using the UCHealth Radiology Imaging Request Form ensures that all pertinent details are captured, facilitating a smoother scheduling process for patients.
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