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ADVANCED IMAGING REQUEST FOR REVIEW FORM Please fax form and supporting documentation to 8776650383 PLEASE COMPLETE ALL FIELDS. Submitted by: Contact:Phone #:Ext/Option #:Worker Information:Fax #:Name:L+I

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How to fill out advanced imaging review request

01

Start by collecting all necessary patient information including name, date of birth, and medical history.

02

Next, ensure you have the specific imaging results that need to be reviewed.

03

Complete the advanced imaging review request form accurately and thoroughly, providing detailed information about the imaging study and any relevant clinical findings.

04

Attach any supporting documentation that may be helpful in the review process, such as previous imaging studies or lab results.

05

Submit the completed request form and supporting documents to the appropriate department or individual for review and approval.

Who needs advanced imaging review request?

01

Medical professionals such as radiologists, oncologists, and surgeons who require a second opinion or expert review of advanced imaging studies.

02

Patients who want to seek a second opinion on their imaging results or wish to have their scans reviewed by a specialist.

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What is advanced imaging review request?

Advanced imaging review request is a form and process used to request a review of advanced imaging services before they are performed.

Who is required to file advanced imaging review request?

Healthcare providers are required to file advanced imaging review request for certain advanced imaging services.

How to fill out advanced imaging review request?

To fill out advanced imaging review request, healthcare providers need to provide patient information, clinical justification, and other relevant details.

What is the purpose of advanced imaging review request?

The purpose of advanced imaging review request is to ensure the necessity and appropriateness of advanced imaging services.

What information must be reported on advanced imaging review request?

On advanced imaging review request, healthcare providers must report patient information, clinical justification, and details of proposed imaging services.

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