Get Va Dynamic Mobile Imaging Exam Request 2016-2025

Filling out the VA Dynamic Mobile Imaging Exam Request form online is a straightforward process that ensures accurate medical imaging services for patients. This guide offers step-by-step instructions to help you complete the form efficiently and accurately.

Follow the steps to fill out the form with ease.

1. Press the ‘Get Form’ button to access the VA Dynamic Mobile Imaging Exam Request and open it in your preferred editor.
2. Complete the date section by entering the appropriate date in the format of MM/DD/YYYY.
3. Fill in the facility information, including the facility name, room number, and wing if applicable.
4. Indicate the person who identified the patient by writing their name in the ID’d by nurse section.
5. Provide the facility's day phone number and an after-hours phone number, along with the facility's fax number.
6. Enter the patient's details, including their full name, date of birth, and social security number.
7. Indicate whether the patient is on a Part A/Skilled stay by selecting 'Yes' or 'No'.
8. Include the patient's insurance details such as Medicare number, Medicaid number, and any other insurance information.
9. Provide the guarantor's information, including their name, phone number, address, city, state, and zip code.
10. Select the requested X-ray exams by checking the corresponding boxes for each exam ordered.
11. Fill in the reason for performing the exam and provide any correlating symptoms.
12. Specify diagnosis codes, indicate if the patient is pregnant, and whether the patient was shielded during the exam.
13. Ensure that you or the guarantor sign the form, providing the date of signing.
14. Once completed, save your changes, download, print, or share the form as needed.

Complete the VA Dynamic Mobile Imaging Exam Request online today to ensure timely imaging services.