Follow the steps to complete your order form successfully.

1. Click ‘Get Form’ button to obtain the document and open it in the editing tool.
2. Enter the patient name in the designated field, including last name, first name, and middle initial.
3. Input the date of birth in the respective section to accurately identify the patient.
4. Fill in the home/cell phone and work phone numbers to ensure effective communication.
5. Provide the mailing address with street, city, state, and zip code to maintain accurate records.
6. Select the date of the exam and appointment time, ensuring they align with calendar availability.
7. Indicate the patient's insurance details, which is crucial for processing the order.
8. Mark whether the patient is pregnant or breastfeeding, as this information is vital for safe imaging practices.
9. List any previous studies with their respective where and when details if applicable.
10. Complete the field for the referring physician, including printing their name and obtaining their signature with the date for authorization.
11. Choose the type of imaging required, such as screening mammography or diagnostic mammography, by checking the appropriate boxes.
12. Fill in the clinical information by selecting one from the provided options and illustrating if required.
13. Confirm authorization for any further procedures as determined by the radiologist by checking the corresponding options.
14. Once all sections are filled accurately, review the form for any errors or missed fields.
15. Finally, save the changes, download, print, or share the completed form as necessary.

Complete your HI Maui Diagnostic Imaging Order Form online today.