Follow the steps to complete the form seamlessly.

1. Click the ‘Get Form’ button to access the form and open it in the designated editor.
2. Enter today's date in the format ____/____/____ to indicate when you are filling out the form.
3. Provide your date of birth (DOB) by filling in the blank space provided.
4. Fill in your full name in the 'Patient Name' section.
5. Enter your employer's name in the specified field.
6. Input your Social Security number (SS#) in the provided space.
7. List your insurance provider's name in the 'Insurance' section.
8. Record your group number and policy number in the corresponding fields.
9. If applicable, indicate whether authorization is needed by filling in that section.
10. Provide contact numbers for your cell phone, home phone, and work phone as necessary.
11. Fill in the details for the appointment date and time in the respective sections.
12. Indicate whether you are pregnant by checking the appropriate box.
13. Fill in the referring physician's name and their office phone, contact, and fax information.
14. Provide the diagnosis in the designated area, ensuring to be as specific as possible.
15. Select any relevant options related to the appointment, such as 'STAT', 'Needs Transportation', or 'Other' as applicable.
16. Choose the type of imaging procedure needed (e.g., MRI, CT, Ultrasound) and specify the requested exams.
17. Sign the form where indicated for the referring physician signature.
18. Review all entered information to ensure accuracy before submitting.
19. Once completed, save the changes, download, print, or share the filled-out form as needed.

Complete your documents online to facilitate your medical imaging experience.