Get the free PET/MR 3T Requisition - wcinyp.org
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Scheduling and service center: 212.746.6000 fax: 646.962.0122 www.wcinyp.com Patient Information Patient Name Insurance DOB NYMPH / MAN No. Insurance ID No. Phone PreAuthorization No. Clinical History/ICD
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How to fill out petmr 3t requisition
How to fill out petmr 3t requisition
01
Start by completing the Patient Information section. Provide the patient's full name, date of birth, and any other required personal details.
02
Fill in the Referring Physician information. Include the physician's name, contact information, and any relevant identification numbers.
03
Indicate the type of exam requested in the Study Information section. Specify that it is a PET/MR 3T requisition.
04
Provide the reason for the exam and any additional clinical information in the Clinical History section. This can help the radiologist interpret the images accurately.
05
Include any relevant laboratory or imaging results in the Attachments section. This can provide further context for the exam.
06
Specify any special instructions, such as fasting or medication restrictions, in the Additional Instructions section.
07
Once all the necessary information is filled out, review the form to ensure accuracy and completeness.
08
Sign and date the requisition form. This verifies that the information provided is true and accurate.
09
Submit the completed requisition form to the appropriate department or facility for scheduling the PET/MR 3T exam.
Who needs petmr 3t requisition?
01
The PET/MR 3T requisition is typically needed by healthcare professionals, such as referring physicians, who are requesting a PET/MR 3T exam for their patients.
02
It may also be required by radiology departments or imaging facilities to ensure proper documentation and scheduling of the examination.
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What is petmr 3t requisition?
Petmr 3t requisition is a form requesting a PET-MR 3T scan, which is a combination of Positron Emission Tomography and Magnetic Resonance Imaging at 3 Tesla.
Who is required to file petmr 3t requisition?
Typically, a physician or healthcare provider is required to file the PET-MR 3T requisition form for a patient.
How to fill out petmr 3t requisition?
The PET-MR 3T requisition form should be filled out by providing patient information, reason for the scan, referring physician details, and any relevant medical history.
What is the purpose of petmr 3t requisition?
The purpose of PET-MR 3T requisition is to request a specific imaging scan that combines PET and MRI technologies for diagnostic purposes.
What information must be reported on petmr 3t requisition?
Patient details, reason for scan, referring physician information, medical history, and any other relevant information must be reported on the PET-MR 3T requisition form.
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