Get the free Imaging Order Referral Form For screening purposes only

For City of Hope inoffice use onlyBreast Imaging Referral Form Phone 6232073241 | Fax 623.932.8631 Email AZreferrals@coh.org cancercenter.com/physiciansPatient name:___ DOB:___ MR#:___ Date of Service:___Please

How to fill out imaging order referral form

How to fill out imaging order referral form

1. Obtain the imaging order referral form from the relevant healthcare provider or facility.
2. Fill out the patient's information including name, date of birth, and contact information.
3. Provide details of the imaging requested, such as the type of imaging (e.g. X-ray, MRI, CT scan) and the body part to be imaged.
4. Include any relevant medical history or conditions that may impact the imaging procedure.
5. Sign and date the form to indicate approval and consent for the imaging procedure.
6. Submit the completed form to the imaging center or healthcare provider as instructed.

Who needs imaging order referral form?

1. Patients who have been referred for imaging procedures by their healthcare provider.
2. Healthcare providers who are requesting imaging services for their patients.

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What is imaging order referral form?

The imaging order referral form is a document used by healthcare providers to request diagnostic imaging services for patients, such as X-rays, MRIs, or CT scans.

Who is required to file imaging order referral form?

Healthcare providers, such as physicians and specialists who are ordering imaging services, are required to file the imaging order referral form.

How to fill out imaging order referral form?

To fill out the imaging order referral form, the provider must complete the patient's information, indicate the type of imaging requested, provide clinical information justifying the order, and sign the form.

What is the purpose of imaging order referral form?

The purpose of the imaging order referral form is to facilitate the proper and necessary imaging services for patients and ensure that the clinical need for the procedure is documented.

What information must be reported on imaging order referral form?

The form must include the patient's personal details, the referring physician's information, the specific imaging requested, relevant clinical history, and any additional instructions or considerations.