Get the free Outpatient Imaging Request Form - University of Illinois College of ... - vetmed ill...

Rev: 5/18/16 ad RDM Outpatient Imaging Request Form University of Illinois UrbanaChampaign Follow these steps: Veterinary Teaching Hospital 1.

How to fill out outpatient imaging request form

How to fill out outpatient imaging request form:

1. Start by writing your personal information such as your full name, date of birth, address, and contact information.
2. Indicate the date and healthcare facility where the imaging request is being made.
3. Provide relevant medical information such as your primary care physician's name, your medical history, and any specific symptoms or concerns you have that require imaging.
4. Specify the type of imaging you are requesting, such as an X-ray, MRI, CT scan, or ultrasound.
5. If applicable, mention any allergies or previous adverse reactions to contrast dye that may be required for certain imaging procedures.
6. If you have any relevant insurance information, include it on the form. This may include your insurance provider's name, policy number, and any pre-authorization requirements.
7. Sign and date the form to acknowledge the accuracy and completeness of the information provided.
8. Submit the completed form to the appropriate department or healthcare provider.

Who needs outpatient imaging request form?

1. Patients who are experiencing specific symptoms or conditions that require diagnostic imaging.
2. Individuals who have been referred by their primary care physician or specialist for further evaluation.
3. Those who require follow-up imaging to monitor the progress or effectiveness of a treatment plan.
4. Patients seeking a second opinion or additional imaging for a specific medical issue.
5. Individuals participating in research studies or clinical trials that require imaging as part of the protocol.

It is important to recognize that the need for an outpatient imaging request form may vary depending on the healthcare facility and the specific requirements of the medical provider responsible for interpreting the imaging results. It is advisable to consult with your healthcare provider or the facility where the imaging will take place to ensure you have the correct form and understand any additional requirements specific to that institution.

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