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Requesting Your
Nonindependent Imaging
Breast Imaging and Reports
This form collects information that is part of the medical record. The Mammography Quality Standards Act (MESA) requires facilities
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How to fill out requesting your non-mayo mammograms
How to fill out requesting your non-mayo mammograms
01
Contact your healthcare provider or the facility where you plan to get your mammogram to request the necessary forms.
02
Fill out the forms completely and accurately. Provide all the required information such as your personal details, contact information, and any relevant medical history.
03
If the forms require a doctor's referral or a specific reason for requesting non-Mayo mammograms, ensure to provide this information.
04
Double-check the forms for any mistakes or missing information before submitting them.
05
Submit the filled-out forms to the designated recipient, either by mailing it to the specified address or delivering it in person.
06
Follow up with the healthcare provider or facility if you haven't received any confirmation or response within a reasonable timeframe.
Who needs requesting your non-mayo mammograms?
01
Anyone who requires mammograms but prefers to have them performed at a facility other than Mayo Clinic can request non-Mayo mammograms.
02
This could include individuals who live in areas where Mayo Clinic may not have a presence, or individuals who have specific preferences regarding healthcare providers.
03
It is advisable to consult with your healthcare provider to determine if non-Mayo mammograms are suitable for your specific situation.
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What is requesting your non-mayo mammograms?
Requesting your non-mayo mammograms refers to the process of obtaining and filing for mammogram services that are not provided by Mayo Clinic facilities.
Who is required to file requesting your non-mayo mammograms?
Individuals who have had mammograms performed outside of Mayo Clinic facilities are typically required to file a request for their non-mayo mammograms.
How to fill out requesting your non-mayo mammograms?
To fill out the request, individuals need to provide personal information, the details of the non-mayo provider, and any relevant medical history related to the mammogram.
What is the purpose of requesting your non-mayo mammograms?
The purpose is to ensure that all medical information is consolidated for accurate diagnosis and treatment, as well as for compliance with health regulations.
What information must be reported on requesting your non-mayo mammograms?
Required information includes the patient's name, date of birth, provider's name, the date of the mammogram, and any pertinent medical history.
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