Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to download the form and open it in your preferred editor.
2. Begin by selecting the appointment date and time. Indicate whether the request is routine or STAT (urgent). Choose the appropriate location from the list provided.
3. In the patient information section, fill in the patient's name, date of birth, social security number, phone number, and cell phone number. Select the type of health coverage (private health or auto insurance).
4. Provide the insurance company's name, subscriber ID, and the employer of the policyholder. Indicate whether translation services are needed by checking 'YES' or 'NO'.
5. Complete the injury and pain information section. Include the diagnosis (ICD-10 codes), date of injury, location of pain, and severity of pain (circle the appropriate option).
6. Document the mechanism of injury and history in the designated fields to provide context for the MRI request.
7. In the referring physician information section, fill out the physician's name, phone number, address, and office location (if different). Ensure that the physician signature is included.
8. Specify the MRI scan information by checking the appropriate technology option and indicating whether contrast is required. Note any relevant lab values, especially for contrast scans, including creatinine and BUN levels.
9. Select the relevant MRI areas based on the patient's condition, ensuring that all necessary sections are marked appropriately in neurology, spine, body, breast, musculoskeletal, vascular imaging, and pelvic categories.
10. Finally, review all the provided information for accuracy. Save changes, then download, print, or securely share the completed form as necessary.

Complete your documents online today for efficient processing and faster results.