Follow the steps to effectively complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the date and the total number of pages at the top of the form. This ensures proper documentation and tracking.
3. Provide the recipient's physician name, followed by the sender's patient name. Make sure these details are accurate to avoid any processing delays.
4. Input the fax number to which the form will be returned, ensuring it is correct to facilitate communication.
5. Complete the patient’s information by entering their name, date of birth, and insurance plan details accurately.
6. List the referring physician's name, specialty, address, city, state, zip code, fax number, and phone number. This is crucial for verification and contact purposes.
7. Fill in the date of the request and the contact person's name to ensure that follow-up can be performed efficiently.
8. Provide the imaging facility's name, site phone number, and address to direct the request appropriately.
9. Indicate the test requested along with the CPT code, ensuring all medical terms are correctly inputted.
10. Answer the sections regarding the working diagnosis, patient symptoms, and duration of symptoms. These details are vital for context.
11. Document the date and findings of the most recent office visit, along with any prior diagnostic testing results, to give the physician all necessary background.
12. List any medications and treatments, including start dates and effectiveness, to provide a comprehensive medical history relevant to the request.
13. If there are any additional histories or clinical facts supporting the examination request, include them in the provided section or on additional sheets.
14. Obtain the physician's signature and date the request to authorize it before final submission.
15. Once all sections are filled, save any changes made to the document, and prepare to download, print, or share the form as needed.

Complete your clinical certification requests online easily and efficiently.