Get Diagnostic Imaging Pre-authorization Exam Requisition Form

The Diagnostic Imaging Pre-Authorization Exam Requisition Form is essential for requesting necessary imaging procedures for patients. This guide provides a step-by-step process to help you accurately complete the form online, ensuring a smooth submission experience.

Follow the steps to complete the requisition form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the patient's name in the designated field. Ensure the spelling is accurate and complete.
3. Provide the patient's date of birth using the format requested. This information is crucial for identifying patient records.
4. Fill in the patient's address, ensuring it is clear and up to date to avoid any communication issues.
5. Enter the patient's telephone number for contact purposes. This should be the number where the patient can be easily reached.
6. Identify the patient's insurance company and provide the relevant ID number for processing purposes.
7. Input the provider's telephone number, which can typically be found on the back of the patient's insurance card.
8. Include the physician’s National Provider Identifier (NPI) and Tax Identification Number (Tax ID) as required.
9. Document the diagnosis for which the imaging exam is requested. This should be precise to facilitate authorization.
10. Describe current symptoms, including their duration and location on the body, to provide context for the imaging request.
11. Summarize the brief medical history of the patient to give the reviewing party insight into the patient's condition.
12. List any recent treatments or medications the patient has been undergoing, along with their duration.
13. If applicable, detail previous imaging results performed outside of the Valley Health System, including dates and results.
14. Include any pathology results if they were performed outside of Valley Health System and are relevant to the request.
15. Finally, review all information for accuracy before saving the completed form, allowing you to easily download, print, or share as needed.

Complete your documents online today for a streamlined process.