EviCore Oncology CT - MR Fax free printable template

Oncology CT MR Fax Reordering ProviderPatient/Member MONUMENT requests, please fax this completed document along with medical records, imaging, tests, etc. If there are any inconsistencies with the

How to fill out EviCore Oncology CT - MR Fax

How to fill out EviCore Oncology CT - MR Fax Form

1. Begin by entering the patient's personal information at the top of the form, including name, date of birth, and insurance details.
2. Fill in the referring physician's information, including name, phone number, and address.
3. Specify the procedure needed, such as CT or MR, including specific body part and reason for the procedure.
4. Include the clinical information and relevant medical history to support the request.
5. Attach any additional documentation or notes that may assist in the review process.
6. Review all entered information for accuracy and completeness.
7. Sign and date the form if required.
8. Submit the form via fax to the designated EviCore number included on the form.

Who needs EviCore Oncology CT - MR Fax Form?

1. Healthcare providers who are referring patients for oncology imaging services.
2. Insurance providers requiring prior authorization for CT or MR scans.
3. Patients who need their oncology imaging requests processed.

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What is EviCore Oncology CT - MR Fax Form?

The EviCore Oncology CT - MR Fax Form is a documentation tool used to request prior authorization for imaging services related to oncology, specifically for CT (Computed Tomography) and MR (Magnetic Resonance) scans.

Who is required to file EviCore Oncology CT - MR Fax Form?

Healthcare providers, such as physicians or medical facilities, who need to obtain prior authorization for oncology-related imaging services are required to file the EviCore Oncology CT - MR Fax Form.

How to fill out EviCore Oncology CT - MR Fax Form?

To fill out the EviCore Oncology CT - MR Fax Form, providers should accurately complete all required fields, including patient information, physician details, request details, and relevant clinical information that supports the need for imaging.

What is the purpose of EviCore Oncology CT - MR Fax Form?

The purpose of the EviCore Oncology CT - MR Fax Form is to facilitate the prior authorization process for necessary imaging services in oncology, ensuring that they are medically justified and covered by insurance.

What information must be reported on EviCore Oncology CT - MR Fax Form?

The information that must be reported on the EviCore Oncology CT - MR Fax Form includes patient demographics, clinical history, the specific imaging studies requested, and any pertinent medical records that provide context for the request.