Get Physician Referral Form - Grossman Imaging Center

Completing the Physician Referral Form for Grossman Imaging Center online can simplify the referral process for practitioners and ensure patients receive timely care. This guide provides a step-by-step approach to filling out the form accurately and efficiently to meet all requirements.

Follow the steps to complete the Physician Referral Form effectively

1. Press the ‘Get Form’ button to access the Physician Referral Form and open it in your preferred document editor.
2. In the section for the patient's information, fill in the patient's name, date of birth, today’s date, appointment date, check-in time, scan time, and daytime phone number.
3. Indicate whether a BUN/Creatinine test has been completed in the last 30 days or if it is to be done at Grossman Imaging by checking the appropriate box.
4. Provide clinical history, symptoms, or diagnosis in the designated field to inform the radiology team of the patient's situation.
5. Enter the patient’s weight, ICD-9 code, and authorization number, if available.
6. Complete the referring physician's information including their name, phone number, and fax number, ensuring all contact details are accurate.
7. Specify if the results are to be treated as STAT by checking the appropriate box, and enter the contact details (name and fax number) for where to send the results.
8. Select the required imaging studies by checking the boxes for MRI, CT, X-ray, etc., and provide any additional details required for each study.
9. Indicate if contrast is required for the imaging study and specify the type of contrast if applicable.
10. Review all information for accuracy, including any special instructions or additional reports required, before submitting the form.
11. Once completed, save your changes, and utilize options to print or share the form as necessary.

Complete your Physician Referral Form online today to streamline the referral process!