PATIENTDIAGNOSTIC IMAGING ORDERPatient Name MRIDOB CT US NUCMEDPhone # XRAY FLOUROEXAMExam Requested DiagnosisICD 10 Patient History Special instructions/Additional exams ID # INSInsurance Carrier.
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How to fill out the Sutter Imaging SMF-694 online
Filling out the Sutter Imaging SMF-694 form online can be a straightforward process when guided correctly. This guide provides a comprehensive step-by-step approach to ensure that all necessary information is accurately presented.
Follow the steps to complete the Sutter Imaging SMF-694 online form
- Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Begin by entering the patient's name in the designated field, followed by their date of birth (DOB). Input the patient's phone number to ensure they can be reached if necessary.
- Select the type of exam being requested from the options provided: MRI, CT, US, NUCMED, XRAY, or FLOURO. Make sure to highlight the correct exam.
- Document the diagnosis along with the associated ICD 10 code in the respective fields to specify the medical issue being addressed.
- Fill out the patient's medical history and include any special instructions or additional exams required in the allocated sections.
- Enter the patient's identification (ID) number and insurance information, including the insurance carrier, medical group, and the insurance phone number.
- If applicable, provide the authorization number for the insurance carrier by typing it into the appropriate field.
- Print the name of the ordering provider and ensure the signature is entered, followed by the provider's date, phone number, and fax number.
- Specify the locations to which reports should be sent by providing names and locations in the designated area.
- Review all entered information for any errors, then proceed to save changes, download, print, or share the completed form as needed.
Complete your Sutter Imaging SMF-694 form online today for a smoother imaging process.
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