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REQUEST FOR MAMMOGRAPHY SERVICES Ordering care provider Date Copy of report to Patient s name DOB *Best daytime phone number to contact patient Alternate *Best week day and/or time for scheduling

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How to fill out a mammogram order form:

1. Start by carefully reading the instructions provided on the form. Familiarize yourself with the required information and any specific guidelines mentioned.
2. Begin by providing your personal details accurately. This may include your full name, date of birth, contact information, and insurance details if applicable.
3. Next, ensure that the referring healthcare provider's information is correctly filled in. This typically includes their name, clinic or hospital name, contact details, and any other necessary identification information.
4. Specify the reason for ordering the mammogram. It could be for routine screening, diagnostic purposes, or follow-up examinations. Include any relevant medical history or indications that may guide the radiologist in interpreting the results.
5. Mention any specific instructions or preferences you may have. For example, if you have breast implants or if you require additional imaging modalities such as ultrasound or magnetic resonance imaging (MRI).
6. If applicable, provide any additional information that may assist with the billing process, such as a referral authorization number, pre-approval, or any financial assistance programs you may be enrolled in.
7. Once you have completed all the necessary sections of the form, review your entries for accuracy and completeness. Make sure all required fields are filled and any supporting documentation is attached if requested.
8. Sign and date the form as required. If someone else is completing the form on your behalf, ensure that their name and relationship to you are included along with their signature.
9. Finally, follow the instructions for submitting the form. This may involve handing it over to the healthcare provider's office, mailing it to a specified address, or submitting it electronically through a secure portal.

Who needs a mammogram order form:

1. Individuals who are advised by their healthcare provider to undergo a mammogram as part of routine screening or due to specific symptoms or risk factors.
2. Healthcare professionals, such as primary care physicians, gynecologists, or specialists, who are ordering the mammogram for their patients based on established guidelines or clinical judgment.
3. Healthcare facilities, including clinics, hospitals, or imaging centers, that require a written order before conducting the mammogram. This may be necessary for billing purposes, to ensure appropriate patient evaluation, and to maintain accurate records.
4. Insurance companies or third-party payers who may request a copy of the mammogram order form to validate the medical necessity of the procedure and process reimbursement claims.

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What is mammogram order form?

A mammogram order form is a document that a healthcare provider fills out to request a mammogram screening or diagnostic procedure for a patient.

Who is required to file mammogram order form?

The healthcare provider, such as a physician or specialist, who is evaluating a patient's breast health is required to file the mammogram order form.

How to fill out mammogram order form?

To fill out a mammogram order form, the healthcare provider must provide patient information, such as name and date of birth, clinical history, specific indications for the mammogram, and any previous imaging results that may be relevant.

What is the purpose of mammogram order form?

The purpose of the mammogram order form is to formally instruct imaging facilities to perform a mammogram and to ensure that relevant medical information is communicated for accurate screening and diagnosis.

What information must be reported on mammogram order form?

The information that must be reported on a mammogram order form includes patient demographics, clinical indications for the mammogram, medical history, and any previous imaging studies or relevant findings.