Follow the steps to fill out the Referral Form smoothly.

1. Click ‘Get Form’ button to obtain the Referral Form and open it in your preferred editing tool.
2. *Provider information: Enter the name of the provider, their phone number, fax number, and signature in the respective fields. Include the clinic name and the order issue date as required.
3. *Patient information: Fill in the patient's name, date of birth, and contact numbers (home, work, cell). Specify the primary insurance and relevant claim/auth number along with the date of injury.
4. Exam requested: Indicate the types of exams requested, including MRI, CT, ultrasound, and x-ray. Specify whether IV contrast is needed and answer any additional exam-related questions.
5. *Reason for exam: Provide details regarding the signs and symptoms that necessitate the exam, any clinical questions, and the diagnosis/ICD-9/10 if applicable, and the patient’s weight.
6. Answer questions regarding the patient's ambulatory status and pregnancy status; check 'Yes' or 'No' accordingly.
7. For recent lab work, indicate if the patient is undergoing CT or MRI with contrast, and fill in any relevant health information and lab dates.
8. Special instructions: Note if the report is stat, and provide the report number if necessary. Include any other specific instructions.
9. Once all sections are completed, review the information for accuracy. Then, save changes, download, or print the completed form as needed.

Complete your Referral Form online today to ensure timely processing of your request.