Universal Healthcare Provider Network, a division of Universal Care Universal House, 15 Tambach Road, Sunninghill Park, Sandton 2191 PO Box 1411, Rivonia 2128 Telephone: +27 11 208 1000 / Fax: 0862.
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How to fill out the UNIVERSAL NETWORK RADIOLOGY REQUEST FORM online
Filling out the UNIVERSAL NETWORK RADIOLOGY REQUEST FORM online is a straightforward process that helps streamline your radiology requests. This guide will walk you through each section of the form to ensure accurate and complete submissions.
Follow the steps to fill out the form accurately and efficiently.
- Press the ‘Get Form’ button to access the form and open it for editing.
- Begin by providing the member’s details, including their surname, identification number or passport number, initials, medical scheme or worker plan, and membership or employee number.
- Next, enter the patient’s details, including their identification number or passport number, surname, first name, age, physical address, dependant code, and postal address.
- In the referring practitioner section, write the doctor’s name, practice number, ICD10 code, and the date of the patient’s appointment.
- Fill in the clinical information with the relevant radiology codes based on the procedures required, specifying the type and area of imaging needed.
- The last section requires the doctor's signature along with the date to validate the request. Ensure you complete this step before finalizing your form.
- Once all fields are filled, you can save changes to the document, download it for your records, print it if needed, or share it as required.
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