CA Stockton Diagnostic Imaging Request 2018-2025 free printable template
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IMAGING REQUEST 1801 E. March Lane, Suite A130, Stockton, CA 95210 Phone: (209) 4759871 Fax: (209) 4749620Please bring this form, all prior related rays and scans, as well as your insurance card and
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How to fill out CA Stockton Diagnostic Imaging Request
How to fill out CA Stockton Diagnostic Imaging Request
01
Start with the patient's personal information, including their full name, date of birth, and contact details.
02
Provide the referring physician's information, including name, contact number, and clinic address.
03
Indicate the type of imaging requested (e.g., X-ray, MRI, CT scan) by selecting the appropriate option.
04
Specify the body part to be imaged clearly (e.g., abdomen, knee, head).
05
Fill in any clinical information or diagnosis to justify the request.
06
Include any relevant previous imaging studies as necessary.
07
Sign and date the form at the bottom.
Who needs CA Stockton Diagnostic Imaging Request?
01
Patients who require diagnostic imaging for medical evaluation or treatment.
02
Referring physicians who need to request imaging for their patients.
03
Healthcare providers involved in patient care who need imaging to assist with diagnosis.
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What is CA Stockton Diagnostic Imaging Request?
CA Stockton Diagnostic Imaging Request is a formal document used to order diagnostic imaging services in Stockton, California.
Who is required to file CA Stockton Diagnostic Imaging Request?
Healthcare providers, such as physicians or specialists, are required to file the CA Stockton Diagnostic Imaging Request for their patients.
How to fill out CA Stockton Diagnostic Imaging Request?
To fill out the CA Stockton Diagnostic Imaging Request, the healthcare provider must provide patient information, select the type of imaging required, and include any relevant clinical information.
What is the purpose of CA Stockton Diagnostic Imaging Request?
The purpose of the CA Stockton Diagnostic Imaging Request is to formally document the need for imaging services to ensure proper patient care and facilitate the billing process.
What information must be reported on CA Stockton Diagnostic Imaging Request?
The CA Stockton Diagnostic Imaging Request must include the patient's name, date of birth, the imaging type requested, the referring physician's information, and a description of the medical necessity for the procedure.
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