2929 Napoleon Avenue New Orleans, LA 70115 Phone: 504-897-8600 Fax: 504-897-8589 www.touro.com/imaging IMAGING CENTER PHYSICIAN S ORDER FORM PATIENT NAME D.O.B. DATE DIAGNOSIS CODE (ICD-9) (REQUIRED).
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How to fill out the Imaging Center Physician's Order Form online
The Imaging Center Physician's Order Form is an essential document for scheduling medical imaging services. Filling out this form accurately is crucial to ensure proper patient care and a smooth imaging experience.
Follow the steps to complete the form seamlessly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the patient's name and date of birth in the designated fields to identify the individual receiving the imaging service accurately.
- Provide the diagnosis code (ICD-9) which is required, along with a clear diagnosis description. Ensure not to include 'rule out,' 'versus,' or 'probable' in this section.
- Ensure that the physician signs the form, as this is a mandatory requirement. Stamps cannot be used.
- Fill in the contact details for preliminary readings, including telephone numbers for reaching the physician.
- Input patient insurance information, including the policy and group numbers, as well as the authorization number if applicable.
- List the referring physician's details, making sure to provide their name, address, and contact information.
- Select the required imaging services from the provided list, which may include CT scans, MRIs, and X-rays. Indicate any specific areas of focus or additional instructions.
- Lastly, confirm the scheduled date and time for the patient's exam. This ensures both the patient and provider are aligned on the appointment details.
- Once all sections are filled out accurately, save your changes and download the completed form. You can then print or share the form as needed.
Start filling out the Imaging Center Physician's Order Form online to ensure your imaging needs are met promptly.
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