Get Il Future Diagnostics Group Mammography Order Form 2023-2025

Filling out the IL Future Diagnostics Group Mammography Order Form online can streamline the process for scheduling necessary mammography services. This guide provides clear, step-by-step instructions to help users navigate and complete the form accurately.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's full name in the designated field along with the date of filling out the form. Make sure the names are spelled correctly for proper identification.
3. Provide the patient's phone number and date of birth. This information will help facilitate any necessary follow-up communication and appointment scheduling.
4. Fill in the referring physician's name and include their signature for authorization. It is essential for the physician to evaluate and specify the diagnostic needs accurately.
5. Complete the office phone and fax number fields for the referring physician's office, ensuring these are current for efficient communication.
6. Next, enter the insurance company’s name, ID number, and group number. Provide the insurance company’s contact phone number and any prior authorization number if applicable.
7. Indicate whether a previous mammogram was performed by checking 'Yes' or 'No.' If applicable, specify where and when it was conducted.
8. Select the type of mammogram needed by checking the appropriate boxes for options such as bilateral, right, left, or baseline exam. Include if it is a screening mammogram with Automated Breast Ultrasound (ABUS) or if it is as an asymptomatic/routine exam.
9. For diagnostic mammograms, check the relevant conditions from the provided options (e.g., history of breast cancer, palpable lump, pain, etc.) and include the appropriate diagnosis codes.
10. If ABUS is needed, check the appropriate options for screening and include any relevant diagnosis codes.
11. For biopsy procedures, check the required procedures and indicate the number of biopsy sites necessary.
12. Complete the breast MRI section by checking the relevant options and provide information about any blood thinning medications the patient may be taking.
13. Finally, review the form for accuracy and completeness. Save changes, download, print, or share the completed form as needed.

Complete the IL Future Diagnostics Group Mammography Order Form online today to ensure timely and accurate healthcare services.