Get Il Future Diagnostics Group Mammography Order Form 2015-2025

Filling out the IL Future Diagnostics Group Mammography Order Form online is a straightforward process that facilitates timely and efficient mammography services. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to complete the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient's name in the designated field. Ensure the spelling is correct for accurate records.
3. Fill in the patient's phone number to facilitate communication regarding the appointment.
4. Enter the current date for the form submission.
5. Input the patient's date of birth to verify age-related eligibility for procedures.
6. Indicate the referring physician's name to maintain proper communication between healthcare providers.
7. Obtain the physician's signature in the appropriate field to authorize the procedure.
8. Provide the physician's office phone number for any follow-up.
9. Enter the physician's office fax number to send documents securely.
10. Complete the insurance company information including name, ID number, group number, and company phone for billing purposes.
11. Indicate if prior authorization is required and provide the prior authorization number if applicable.
12. Specify whether the patient has had a previous mammogram and, if so, provide details on where and when it was performed.
13. Select the type of examination by checking the appropriate box for screening or diagnostic mammogram and specify the laterality (bilateral, right, or left).
14. Fill in the ICD-10 code that corresponds to the type of examination to ensure proper coding and billing.
15. For specific diagnostic conditions, check the appropriate boxes describing the patient's history and symptoms.
16. Complete the sections for 3D tomosynthesis based on the type of procedure indicated.
17. Indicate any necessary preparation instructions relevant to the patient prior to their appointment.
18. Record any allergies and medications affecting the procedure, ensuring all information is accurate and complete.
19. Finally, review all entered information for accuracy, save changes, and decide if you would like to download, print, or share the form as needed.

Complete your IL Future Diagnostics Group Mammography Order Form online today for streamlined care.