NY Main Street Radiology MRI Questionnaire 2019-2025 free printable template

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MRI QUESTIONNAIRE Patient Name:DOB:ACC:MAN:Age:Referring Provider:1. Do you have a pacemaker or any type of cardiac device/stents? 2. Have you had any brain surgery or brain clips? 3. Have you ever

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How to fill out NY Main Street Radiology MRI Questionnaire

01

Start by carefully reading the instructions at the top of the MRI Questionnaire.

02

Fill in your personal information, including your name, date of birth, and contact details.

03

Provide details about your medical history, including any previous surgeries or relevant conditions.

04

List any current medications you are taking, along with dosages.

05

Answer questions related to allergies, especially to contrast agents, if applicable.

06

Indicate if you have any implants or devices that may affect the MRI procedure.

07

Review your answers to ensure accuracy and completeness.

08

Sign and date the questionnaire at the bottom.

Who needs NY Main Street Radiology MRI Questionnaire?

01

Individuals scheduled for an MRI at NY Main Street Radiology.

02

Patients who have a history of certain medical conditions that need to be reviewed prior to an MRI.

03

Anyone who has had previous imaging or surgical procedures that may affect the MRI assessment.

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What is NY Main Street Radiology MRI Questionnaire?

The NY Main Street Radiology MRI Questionnaire is a document designed to collect essential information regarding MRI services provided by main street radiology facilities in New York.

Who is required to file NY Main Street Radiology MRI Questionnaire?

Any radiology facility offering MRI services in New York is required to file the NY Main Street Radiology MRI Questionnaire.

How to fill out NY Main Street Radiology MRI Questionnaire?

To fill out the NY Main Street Radiology MRI Questionnaire, facilities must gather the necessary information, complete each section accurately, and submit the questionnaire by the designated deadline.

What is the purpose of NY Main Street Radiology MRI Questionnaire?

The purpose of the NY Main Street Radiology MRI Questionnaire is to ensure compliance with regulations, assess service quality, and monitor MRI utilization among radiology facilities.

What information must be reported on NY Main Street Radiology MRI Questionnaire?

The information that must be reported includes facility details, types of MRI services offered, usage statistics, patient demographics, and compliance with safety and quality standards.

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