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Imaging Referral Form 19×9/08 16:31 Cardiff Bay Clinic, Celtic Gateway, Dunleavy Drive, Cardiff. CF11 0SN Tel: 02920 836799 F: 02920 232100-Page 1 IMAGING REFERRAL FORM PATIENT DETAILS Title: Name:

How to fill out imaging referal form

How to Fill Out Imaging Referral Form?

1. Obtain the imaging referral form: Contact your healthcare provider's office or radiology department to request a copy of the imaging referral form. They may provide it to you in person, by mail, or electronically.
2. Complete your personal information: At the top of the form, provide your full name, date of birth, contact information, and any other pertinent details required. This ensures that the imaging facility can properly identify you and provide accurate results.
3. Provide details about your healthcare provider: In the designated section, provide the name, phone number, and address of the healthcare provider who is referring you for the imaging test. This information helps the imaging facility communicate with your healthcare provider and send the results to the appropriate individual.
4. Specify the type of imaging test: Indicate the type of imaging test being requested, such as X-ray, MRI, CT scan, ultrasound, or mammogram. Be as specific as possible to avoid any confusion.
5. Include any relevant medical history: If you have any pre-existing medical conditions, allergies, or previous imaging studies related to the current issue, ensure to mention them in the appropriate section. This information can assist the radiologist in interpreting your results accurately.
6. Provide information about symptoms or reason for imaging: Describe the symptoms you are experiencing or the reason why your healthcare provider is referring you for the imaging test. This helps guide the radiologist's evaluation and ensures they focus on the relevant areas.
7. Verify insurance and payment details: If required, fill in the insurance information, including your insurance provider's name, policy number, and any other necessary details. Double-check to ensure accuracy. If you are self-paying, make sure to inquire about the payment options available.
8. Obtain necessary signatures: Review the form thoroughly and sign and date it in the designated areas. If you have a legal guardian or representative, they might need to sign the form as well.
9. Submit the form: After completing the imaging referral form, follow the instructions provided by your healthcare provider or imaging facility to submit it. This may require hand-delivering it to the appropriate location, sending it by mail, or uploading it through an online portal.

Who Needs Imaging Referral Form?

1. Patients requiring specialized imaging tests: A referral form is typically needed for patients who require specialized imaging tests beyond basic X-rays, such as CT scans, MRIs, ultrasounds, or mammograms.
2. Patients referred by healthcare providers: Imaging referral forms are necessary for patients who have been referred by their primary care physicians, specialists, or other healthcare providers. This ensures that the imaging facility knows the specific test requested and can collaborate with the referring healthcare provider.
3. Insured patients claiming insurance coverage: Those seeking insurance coverage for the imaging test may require a referral form to comply with their insurance provider's policies. The form helps validate the necessity of the test and facilitates the insurance claims process.
4. Self-paying patients: Even if not seeking insurance coverage, self-paying patients may still need to fill out an imaging referral form. This allows the imaging facility to document patient information, track the requested test, and ensure appropriate billing and payment processing.

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What is imaging referal form?

Imaging referral form is a document used to request imaging procedures such as X-rays, MRIs, or CT scans for patients.

Who is required to file imaging referal form?

Healthcare providers such as doctors, physicians, or specialists are required to file imaging referral forms.

How to fill out imaging referal form?

Imaging referral forms are typically filled out by providing patient information, the type of imaging procedure requested, and the reason for the referral.

What is the purpose of imaging referal form?

The purpose of imaging referral form is to ensure that patients receive the necessary imaging procedures in a timely manner.

What information must be reported on imaging referal form?

Information such as patient's name, date of birth, referring provider's information, type of imaging procedure requested, and reason for the referral must be reported on imaging referral form.