Get the free EXTREMITY MRI ORDER FORM

EXTREMITY MRI ORDER FORM Contact us toll-free: Call 1-866-398-7364 or Fax 1-866-267-0144 Excellence in Extremity MRI Tax ID 04-3627188 Thank you for choosing EIP! NPI 1528058245 Patient s Name Patient

How to fill out extremity mri order form

How to fill out an extremity MRI order form:

1. Start by providing your personal information: Enter your full name, date of birth, address, and contact details (phone number and email address).
2. Next, mention your referring physician: Write the name, address, and contact information of the physician who is ordering the MRI.
3. Specify the reason for the extremity MRI: Indicate the specific body part that requires imaging, such as the shoulder, elbow, wrist, hand, hip, knee, ankle, or foot.
4. Include relevant medical history: Mention any relevant medical conditions, previous surgeries, or injuries that may be necessary for the radiologist to know before interpreting the MRI results.
5. Provide insurance information: Enter the details of your insurance provider, including the name, policy number, and any authorization or referral numbers required.
6. Choose the preferred facility and appointment date: If you have a particular MRI facility in mind, write down its name and address. Select a convenient appointment date and time, if applicable.
7. Sign and date the form: Read through the form carefully, ensuring all information is correct, and sign and date it as required.
8. Keep a copy for your records: Make a photocopy or take a clear picture of the filled-out form for your personal records.

Who needs an extremity MRI order form:

1. Individuals experiencing pain or swelling in their extremities (such as the shoulder, elbow, wrist, hand, hip, knee, ankle, or foot) that requires further evaluation.
2. Patients whose physicians suspect bone fractures, joint abnormalities, ligament or tendon injuries, tumors, infections, or other conditions affecting the extremities.
3. Athletes or individuals involved in physically demanding activities who have sustained injuries or want to assess their musculoskeletal health.
4. Individuals with arthritis or degenerative joint diseases who require ongoing monitoring of their condition.
5. Patients going through pre or post-surgical assessments that involve the extremities.
6. Individuals looking to investigate the causes of chronic pain or limited mobility in their extremities.
7. Workers who have experienced work-related injuries or accidents affecting their extremities, requiring evaluation for medical or legal purposes.

Note: It is essential to consult with a healthcare provider or physician to determine if an extremity MRI is necessary and to obtain a proper referral before filling out the order form.

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What is extremity mri order form?

The extremity MRI order form is a document used to request a magnetic resonance imaging scan for a specific body part, such as a hand, foot, or knee.

Who is required to file extremity mri order form?

Healthcare providers, such as doctors or specialists, are typically required to fill out the extremity MRI order form for their patients.

How to fill out extremity mri order form?

The extremity MRI order form usually requires the healthcare provider to fill out the patient's information, reason for the MRI, specific body part to be scanned, and any relevant medical history.

What is the purpose of extremity mri order form?

The purpose of the extremity MRI order form is to ensure that patients receive the necessary MRI scans for their specific body parts and conditions.

What information must be reported on extremity mri order form?

The extremity MRI order form typically requires information such as patient's name, date of birth, reason for MRI, specific body part to be scanned, and healthcare provider's contact information.