Get Ancillary Services Scheduling Order Form - Novant Health Imaging

Filling out the Ancillary Services Scheduling Order Form is essential for scheduling various imaging and ancillary services at Novant Health. This guide provides clear, step-by-step instructions to help you complete the form online with ease.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate which facility this request is for by selecting one option from the following: PH Charlotte, PH Matthews, or PH Huntersville.
3. Select the required services by checking the appropriate boxes under the Cath/EP Lab & Non Invasive Cardiology, Outpatient Infusion, Neurophysiology, or Pulmonary Function sections. If applicable, provide additional information where necessary.
4. Fill in the indication(s) for the requested services in the designated section.
5. Enter the ICD-9 code(s) relevant to the patient's condition.
6. Provide patient information including their name, date of birth, and social security number. Additionally, fill in contact numbers under home, work, and cell.
7. Select the appointment preference by checking the desired days of the week and indicate if an appointment is needed as soon as possible or within 1-3 days.
8. Indicate any special assistance requirements, including wheelchair needs or interpreter services, and provide details as necessary.
9. Confirm whether the medication list and insurance cards have been sent by marking ‘Yes’ or ‘No’.
10. Complete the primary and secondary insurance information, including insurance ID numbers and group details.
11. Fill out the office contact information as well as the ordering physician’s name and contact information.
12. Have the ordering physician sign the form and enter the date.
13. Finally, select the appointment date and time desired, and any necessary preparation instructions.
14. Upon completion, ensure to save changes, download, print, or share the form as required.

Complete your Ancillary Services Scheduling Order Form online today for efficient service.