Get X Ray Referral Form

Filling out the X Ray Referral Form online is a straightforward process that helps streamline your referral for imaging services. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the X Ray Referral Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information in the designated fields. This includes the patient’s name, date of birth, weight, height, and any known drug allergies. Make sure to confirm that the weight does not exceed 500 lbs.
3. Input contact numbers for the patient, including home, work, and cell numbers. This information is crucial for scheduling appointments.
4. Provide insurance details. Fill in the insurance company name, the insurance ID number, and pre-authorization number if applicable. If this relates to a motor vehicle accident or workers' compensation case, include relevant company and claim information.
5. Complete the section requiring the physician's signature and adjuster’s contact information. Ensure that all details are accurate to avoid delays in processing.
6. Select the routine exams that apply to the patient. For each examination type, specify the required views. Mark the appropriate boxes for spine, upper extremity, lower extremity, and any additional views as instructed.
7. Describe any other radiographic exams not listed by filling in the specific tests in the provided area.
8. List any signs and symptoms experienced by the patient and include the corresponding ICD code if available.
9. After completing all required sections, you can save your changes. Options may include downloading, printing, or sharing the form for further steps.

Start filling out your X Ray Referral Form online now for a seamless referral process.