Get Hi Kapiolani Medical Center Imaging Outpatient Procedure Request Form 2020-2025

Filling out the HI Kapiolani Medical Center Imaging Outpatient Procedure Request Form online is a straightforward process. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the patient's name by providing the last name, first name, and middle initial. Make sure this is clearly legible.
3. Next, input the date of service in the designated area using the format MM/DD/YYYY.
4. Fill in the patient's date of birth in the same format as the date of service.
5. Provide the patient's home phone number to ensure they can be contacted if needed.
6. Enter the patient's insurance information in the space provided to verify coverage for the procedure.
7. Specify the time of the exam by entering the appropriate time in the designated field.
8. Describe the procedure the patient is to undergo by providing details in the relevant section.
9. Document any personal or family medical history related to the procedure in the history section.
10. In the symptoms and chief complaint section, include specific signs, symptoms, or complaints related to the procedure.
11. List any questions intended to be answered during the appointment.
12. If applicable, indicate if this is for workers' compensation and fill out any relevant details.
13. Ensure that the physician signs the form and includes the date and printed name.
14. Fill in the office phone number and office fax number for further communication if necessary.
15. Indicate where you would like the copy of the report sent, and specify if the patient will return to the office or if only films are needed.
16. Lastly, input decision support information if required and confirm its completion.
17. Once all fields are filled out accurately, save your changes, and choose to download, print, or share the form.

Complete your documents online with ease today!