Follow the steps to complete the form online.

1. Click the 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the patient’s personal information. Fill in the patient's name as it appears on their insurance card, date of birth (DOB), and contact details, including cell and home phone numbers.
3. Provide relevant medical data including the patient’s height and weight. Ensure this information is accurate for effective medical evaluation.
4. Enter the insurance details. Include the primary insurance provider's name and ID number. If applicable, also include secondary insurance information.
5. If the appointment is related to a workers' compensation or auto injury, check the respective boxes and provide the date of injury if needed.
6. Specify any required pre-certification by either checking the box to obtain authorization or by noting the pre-certification number if it is already obtained.
7. Clearly state the written diagnosis, reason, or symptom for the exam(s). Include specific clinical indications to demonstrate the medical necessity of each test.
8. Indicate whether the exam or procedure is related to an injury by checking the appropriate response. If yes, clarify whether it is an initial visit, a subsequent visit, or a sequela.
9. Have the medical provider sign and date the form in the designated area. The provider's printed name and practice name must also be included.
10. Select the desired reporting method, such as whether to receive the report via fax or phone call, and ensure the provider's fax number is noted if faxing is chosen.
11. Complete the imaging requirements by indicating the specific exams needed, ensuring any additional notes are clear and understandable.
12. Once all sections are filled, review the completed form for accuracy. Save your changes, then download, print, or share the form as necessary.

Start completing the Marshwood Imaging Center Order Form - CDI online today to ensure timely processing of your imaging services.