Follow the steps to effectively complete the form.

1. Click the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the appointment date and check-in time to specify when your imaging session is scheduled.
3. Select the location of your appointment from the available options: Port Orchard, Bremerton, Poulsbo, or Silverdale. This is important for ensuring you go to the correct facility.
4. Complete the 'Date of Referral' section and provide the name of the referring provider. This helps maintain a clear line of communication between the facilities and your healthcare provider.
5. Obtain the referring provider's signature, confirming the necessity of the imaging, and ensure this is filled in accordingly.
6. Enter the patient's name, contact information, height, weight, and indicate if the patient is pregnant.
7. Provide insurance information, including the authorization number if applicable. This is essential for billing purposes.
8. In the 'Written Diagnosis/Reason/Symptom for Exam(s)' section, input the specific medical necessity for the imaging. Ensure you provide definitive diagnoses as required by Medicare policies.
9. Input any necessary lab results or test details, such as BUN/Creatinine levels, and their drawn date. If requested, fax results as specified.
10. Select the type of imaging required from the various categories (e.g., MRI, CT, ultrasound) and specify any additional details where required.
11. Fill out the 'Reporting' preferences to indicate how you would like to receive results, whether routine or stat.
12. Finally, review the entire form for accuracy and completeness before you save changes, download, print or share the finished document.

Complete your imaging order form online to ensure a seamless experience for your diagnostic needs.