Get Fax Request Form - Emednyorg

The Fax Request Form - EMedNYorg is a vital tool for facilitating consultations related to advanced imaging services. This guide will walk you through the necessary steps to expertly complete the form online.

Follow the steps to complete the Fax Request Form confidently.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the date and time in the designated fields to accurately reflect when the request is being made.
3. Fill in the contact name and contact phone number for the individual completing the form.
4. Under the patient information section, provide the patient’s name, ID number, and date of birth.
5. Input the group number relevant to the patient's insurance or healthcare coverage.
6. Complete the ordering physician and rendering facility information by entering the name of the ordering practitioner and the rendering facility.
7. Provide the phone number and fax number for the rendering facility.
8. Specify the patient diagnosis and corresponding code along with the procedure name and code.
9. Include the ICD-10 code relevant to the patient’s condition.
10. Detail the patient symptoms and duration to provide context for the imaging request.
11. List the CPT code associated with the proposed procedure.
12. Document any patient medications along with their duration.
13. Summarize any prior imaging and laboratory studies and their results to ensure comprehensive treatment consideration.
14. Review the confidentiality notice and ensure understanding of the implications of the information being submitted.
15. Once you have completed the form, ensure all information is accurate before saving changes, downloading, printing, or sharing the form.

Complete your Fax Request Form online today to streamline your imaging consultations.