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(Diagnostic Imaging Requisition Form) . . . . 44000 043021021 7775SDVHFMRT001 Rev. 04/04/66 (Patient Name) :

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How to fill out diagnostic imaging order referral

01

Obtain the necessary patient information such as name, date of birth, and medical history.

02

Consult with the referring physician to determine the type of diagnostic imaging needed.

03

Fill out the diagnostic imaging order referral form with the required information including patient details, type of imaging needed, reason for the referral, and referring physician's information.

04

Submit the completed referral form to the diagnostic imaging center for processing.

Who needs diagnostic imaging order referral?

01

Patients who have been recommended by their physician to undergo diagnostic imaging tests.

02

Physicians who need to refer their patients for specific diagnostic imaging procedures.

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What is diagnostic imaging order referral?

Diagnostic imaging order referral is a process through which a healthcare provider requests imaging services (such as X-rays, MRIs, or CT scans) to obtain diagnostic information about a patient's condition.

Who is required to file diagnostic imaging order referral?

Healthcare providers, such as physicians and specialists, are required to file diagnostic imaging order referrals to ensure proper authorization and facilitate the imaging process.

How to fill out diagnostic imaging order referral?

To fill out a diagnostic imaging order referral, the healthcare provider must include patient information, the specific imaging test required, clinical indications, and their signature or electronic authentication.

What is the purpose of diagnostic imaging order referral?

The purpose of diagnostic imaging order referral is to provide a structured means for healthcare providers to communicate the need for imaging services, ensuring that appropriate tests are performed for diagnosis and treatment.

What information must be reported on diagnostic imaging order referral?

The information that must be reported includes the patient's name, date of birth, specific imaging procedure requested, clinical history, and the provider's details.

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