Get Dakotacare Specialized Imaging Notification Form - Ms_015 ...

Completing the DAKOTACARE Specialized Imaging Notification Form online requires careful attention to detail. This guide will provide you with a step-by-step approach to ensure that your form is filled out accurately and submitted correctly.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the date of notification. This is the date you are completing the form.
3. Provide ordering provider information by filling out the fields for the provider's name, title, clinic name, address, phone number, and fax number. This information is crucial for identifying who is requesting the imaging services.
4. Complete the imaging facility section with the facility's name, address, phone number, and fax number.
5. In the imaging/clinical information section, specify the imaging study or procedure by selecting the appropriate options. Ensure to include the CPT code, indicating whether the service will be done with or without contrast.
6. Input the dates of service for the imaging studies. If there are multiple, ensure both dates are clearly indicated.
7. Document the diagnosis reason for the test and include the corresponding ICD code to support the medical necessity of the imaging services.
8. Provide a clinical history by listing previous relevant treatments, testing, and imaging related to the diagnosis.
9. Use the additional comments section for any other information that may be relevant to the request.
10. Lastly, fill in the completed by section, including the facility name, contact phone number, and fax number.

Submit your documents online to ensure timely processing and avoid any delays.