Get Diagnostic Imaging Referral Form - June 2014. Diagnostic Imaging Referral Form - June 2014

The Diagnostic Imaging Referral Form is essential for facilitating communication between healthcare providers regarding patient imaging needs. This guide provides clear, step-by-step instructions to help you accurately complete the form online.

Follow the steps to easily complete the Diagnostic Imaging Referral Form.

1. Press the ‘Get Form’ button to acquire the Diagnostic Imaging Referral Form and open it in your preferred editing tool.
2. Enter the patient's name in the designated field, followed by their date of birth and EPIC number.
3. Fill in the home, work, and cell phone numbers, ensuring to circle the best number to reach the patient during daytime hours.
4. In the 'Exam Requested' section, specify the imaging procedure the patient requires.
5. Under 'Indications / Diagnosis', provide a concise explanation of the clinical reasons for the imaging request.
6. Document the patient's medical history in the 'Patient History' section and enter the relevant ICD-9 codes.
7. Check the acknowledgment box indicating you have reviewed Sutter Imaging's standard operating procedures.
8. Complete the insurance carrier or medical group information along with the insurance ID number and phone number.
9. If prior authorization is required, include the authorization number.
10. Sign the form in the 'Ordering Provider' section and enter your name.
11. Indicate where to send the reports by listing names and locations.
12. Enter the date the form is completed, along with contact details where reports can be sent.
13. Finally, review your entries for accuracy and clarity before saving changes, downloading, printing, or sharing the completed form.

Start filling out your Diagnostic Imaging Referral Form online today to ensure seamless coordination of care.