Get 185573 Grapevine-hurst V11 - Preferred Imaging

Completing the 185573 Grapevine-Hurst V11 - Preferred Imaging form online is a straightforward process designed to facilitate your medical imaging needs. This guide provides a detailed, step-by-step approach to ensure you correctly fill out the form and submit it efficiently.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to download the form and access it in the online editor.
2. Enter the current date in the designated field at the top of the form. Use the format MM/DD/YYYY for clarity.
3. Fill in the patient’s name in the provided space, ensuring accurate spelling for effective communication.
4. Complete the date of birth section using the same MM/DD/YYYY format.
5. Provide both cell phone and home phone numbers where indicated, making sure to include area codes.
6. List the referring physician's name clearly in the designated field, followed by their phone number in the required format.
7. Provide the office contact name if necessary, along with their fax number if applicable.
8. State the reason for the exam or symptoms in the relevant section, being as specific as possible.
9. If the referring physician has a specific request such as 'STAT report' or transportation needs, indicate these options clearly.
10. Fill in the diagnosis ICD-10 code if available, ensuring it is accurate and clearly written.
11. Select the types of imaging procedures needed by checking the appropriate boxes and indicating any specifics required.
12. If sedation is requested, mark the correct box for or , and provide the drug name if applicable.
13. Review all filled sections to ensure accuracy. Once satisfied, proceed to save changes, download the completed form, or print it as required.

Complete your documents online now to streamline your imaging process.