Follow the steps to complete the 7043847226 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Prior Imaging' section, provide the date and location of any previous imaging. This information is essential for scheduling and ensuring continuity of care.
3. For the 'Patient to Call' section, fill in the patient’s phone number and cell number to facilitate communication for scheduling.
4. Enter the date of birth (DOB) of the patient to verify their identity and ensure accurate record-keeping.
5. In the 'Diagnosis/Signs/Symptoms' field, describe the necessary medical details to inform scheduling and imaging decisions.
6. The physician must sign the form for authorization. Please include their name, signature, and any identifying number if required.
7. Complete the 'Insurance Carrier' section by providing the name of the insurance provider, authorization number, and the facility for which the authorization is applicable.
8. Select the type of contrast needed for the imaging procedures. Choose from options such as 'With & Without' or 'Without' based on the physician's recommendation.
9. Fill out the specific imaging tests requested under the appropriate sections (Head/Neck, Body, Spine, etc.), ensuring that all necessary fields are completed accurately.
10. Once all sections are filled out, carefully review the form for any errors or omissions. Ensure all required fields are completed.
11. Finally, save your changes, and download, print, or share the completed form according to your needs.

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