Get Radiology Request Form

Filling out the Radiology Request Form online is a straightforward process that ensures your medical imaging needs are communicated clearly. This guide will provide you with step-by-step instructions to complete each section accurately and efficiently.

Follow the steps to complete the Radiology Request Form online

1. Click 'Get Form' button to obtain the Radiology Request Form and open it in your preferred editing tool.
2. Begin by entering the date at the top of the form. This provides a reference for the request and any relevant schedules.
3. Fill out the patient's information, including their name, medical record number (MR #), date of birth (DOB), age, height, weight, and gender. Ensure accuracy, as this data is vital for identification.
4. In the insurance section, input the insurance company name and any pre-authorization number if required. Indicate whether the bill should be submitted to insurance by checking 'Yes' or 'No'.
5. For the study requested, provide a clear diagnosis or indication in the designated area. Be sure to include any additional information that may be requested from the exam, ensuring all comments are printed legibly.
6. Select the appropriate categories from the options provided, detailing any specific conditions relating to the abdomen, pelvis/scrotal/transvaginal, or vascularity/Doppler studies by marking or highlighting the relevant items.
7. Under appointment information, write down the appointment date, prep instructions for the patient, appointment time, and location. This section is for internal use, but accuracy helps streamline processing.
8. Complete the fields regarding the referring physician's name, signature, and contact information. This ensures the request is valid and can be processed without delay.
9. After completing the form, review all entries for accuracy. Save any changes made to the document. You can download, print, or share the completed form as required for submission.

Complete your Radiology Request Form online today to ensure timely medical imaging services.