Get Referral Form - Las Vegas Radiology

Filling out the Referral Form for Las Vegas Radiology online is a straightforward process that ensures you provide all necessary information for your imaging needs. This guide will walk you through each section of the form to help you complete it accurately and efficiently.

Follow the steps to complete your referral form with ease.

1. Click ‘Get Form’ button to access the online version of the Referral Form.
2. Begin by providing the patient's information in the designated fields. Include the patient's name, date of birth, age, and select their gender.
3. Fill in the patient's contact information, including home, cell, and work phone numbers as applicable.
4. If applicable, indicate whether there is a lien or personal injury attorney involved by completing the relevant section.
5. Provide the date of injury (DOI) if relevant, and fill in insurance information, including the insurance provider and ID/claim number.
6. Detail the diagnosis or symptoms to ensure the radiology team understands the medical context.
7. In the exam request section, select the pertinent exams and indicate any specifications such as the use of contrast.
8. Consent to represent by providing the necessary information for the prior authorization process, including the ordering provider’s NPI and company tax ID.
9. Fill in the referring physician’s information along with their contact details. This is important for communication and follow-up.
10. Specify the desired appointment details and any urgency in receiving the report.
11. Review all information entered for accuracy before proceeding to save your changes, download, print, or share the completed form.

Complete your referral form online today to ensure your imaging needs are addressed promptly.