Get Pediatric Imaging Order Form

This guide provides clear instructions on how to accurately complete the Pediatric Imaging Order Form online. By following these steps, you will ensure that all necessary information is included, facilitating a smooth imaging process for pediatric patients.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the Pediatric Imaging Order Form and open it in the necessary online editor.
2. Enter today's date in the designated field at the top of the form.
3. Fill in the patient’s last name and first name in the required fields.
4. Input the patient’s date of birth to help identify and match the records accurately.
5. Provide a daytime phone number for the patient, ensuring communication is possible if needed.
6. Complete the ordering clinician's information, including their name and office location, if multiple locations exist.
7. Indicate whether the patient should go or wait for the examination by selecting the appropriate option.
8. Select the urgency of the report by choosing either 'Routine' or 'STAT' and provide a direct phone number for STAT call reporting if applicable.
9. Enter the insurance information and any prior authorization number, if required.
10. Detail the symptoms, diagnosis, or history relating to the patient's condition, including any necessary ICD-9 codes.
11. Choose the required imaging exam from the provided options and, if the exam is not listed, describe it in the exam description field.
12. Have the clinician sign the form in the designated area. Note that stamped signatures are not acceptable.
13. Review all the filled fields for accuracy and completeness before finalizing your submission.
14. Once completed, save your changes, and choose to download, print, or share the form, as necessary.

Complete your Pediatric Imaging Order Form online today to ensure prompt processing and care.