Get the free Imaging Request Form FOR IMAGING USE ONLY - Lister Hospital

Imaging Request Form Please fax completed form to +44 ×0×20 7259 0138 FOR IMAGING USE ONLY For inquiries, call +44 ×0×20 7730 3759 PATIENT DETAILS IMAGING APPOINTMENT DETAILS TITLE DATE SURNAME

How to fill out imaging request form for

How to Fill Out Imaging Request Form?

Start by entering your personal information:

1. Provide your full name, including your first name, middle name (if applicable), and last name.
2. Include your contact information such as your phone number and email address.
3. Enter your mailing address, including the street name, city, state, and ZIP code.

Specify the type of imaging requested:

1. Indicate the specific type of imaging you need, whether it's an X-ray, MRI, ultrasound, CT scan, etc.
2. Provide any relevant details regarding the area or body part that needs imaging.

Include your healthcare provider's information:

1. Enter the name of your referring healthcare provider or physician.
2. Include their contact information, such as their phone number and the name of their medical practice or facility.

Mention any previous imaging or medical history:

1. If you have undergone any previous imaging procedures relevant to the current request, provide a brief summary.
2. Include any pertinent medical history that might assist in interpreting the imaging results.

Specify insurance details (if applicable):

1. If you have health insurance, provide your insurance information, including the name of your insurance company and your policy or member number.
2. Include any required authorization or referral numbers, if applicable.

Sign and date the form:

1. Read through the entire form carefully, ensuring you have completed all the necessary sections.
2. At the bottom of the form, sign and date it to acknowledge that the information provided is accurate.

Who Needs Imaging Request Form For?

Patients requiring diagnostic tests:

1. Individuals who need to undergo diagnostic imaging procedures as part of their medical evaluation, diagnosis, or treatment may need to fill out an imaging request form.
2. This includes patients with suspected fractures, internal injuries, tumors, or other medical conditions that can be diagnosed or monitored through imaging.

Healthcare providers:

1. Physicians, doctors, surgeons, and other healthcare professionals who order imaging tests for their patients need to fill out imaging request forms.
2. These forms help communicate their specific imaging requirements to the imaging center or hospital.

Imaging centers or hospitals:

1. The staff at imaging centers or hospitals who receive imaging requests from patients or healthcare providers need the completed imaging request forms to schedule and perform the requested procedures.
2. These forms serve as a reference for the type of imaging required, patient information, and any additional instructions or considerations for conducting the imaging.

In summary, filling out an imaging request form involves providing personal information, specifying the type of imaging needed, including healthcare provider details, mentioning any relevant medical history, providing insurance information (if applicable), and signing the form to authenticate the information. This form is required by both patients in need of imaging tests and healthcare providers who order these tests. It also serves as documentation for imaging centers or hospitals to schedule and perform the requested procedures accurately.

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What is imaging request form for?

The imaging request form is used to request imaging services such as X-rays, MRIs, or CT scans.

Who is required to file imaging request form for?

Patients or healthcare providers may be required to file an imaging request form depending on the medical facility's policies.

How to fill out imaging request form for?

The imaging request form should be completed with patient information, type of imaging needed, reason for imaging, and any other relevant details.

What is the purpose of imaging request form for?

The purpose of the imaging request form is to facilitate the scheduling and documentation of medical imaging services.

What information must be reported on imaging request form for?

The imaging request form should include patient demographics, insurance information, referring physician details, and the specific imaging test being requested.