Get the free Diagnostic Imaging Request Form for Non-medical Referrers
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Diagnostic Imaging Request Form for Nonmedical Referrers
The David Thompson Imaging Suite
Imaging Department, 5054 Beaumont Street, London, W1G 6DW
Tel: 020 7467 4317 / 020 7467 4582 Fax: 020 7467
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How to fill out diagnostic imaging request form
How to fill out diagnostic imaging request form
01
Obtain the diagnostic imaging request form from the healthcare provider.
02
Fill out the patient's personal information such as name, date of birth, and contact information.
03
Provide details about the specific type of diagnostic imaging needed such as X-ray, MRI, CT scan, etc.
04
Indicate the reason for the diagnostic imaging request and any relevant medical history.
05
Include the referring healthcare provider's information and signature on the form.
06
Submit the completed form to the imaging center or hospital for processing.
Who needs diagnostic imaging request form?
01
Patients who have been referred for diagnostic imaging by their healthcare provider.
02
Healthcare providers who are requesting diagnostic imaging services for their patients.
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What is diagnostic imaging request form?
A diagnostic imaging request form is a document used by healthcare providers to order specific imaging tests, such as X-rays, MRIs, or CT scans, for patients to aid in diagnosis.
Who is required to file diagnostic imaging request form?
Healthcare providers, such as physicians, radiologists, or other qualified medical professionals, are required to file a diagnostic imaging request form.
How to fill out diagnostic imaging request form?
To fill out a diagnostic imaging request form, a healthcare provider should provide patient information, specify the type of imaging required, state the clinical indication or reason for the request, and include any relevant patient history.
What is the purpose of diagnostic imaging request form?
The purpose of the diagnostic imaging request form is to ensure that appropriate imaging studies are ordered based on medical necessity for accurate diagnosis and treatment.
What information must be reported on diagnostic imaging request form?
The information that must be reported includes patient demographics, healthcare provider information, specific imaging test requested, clinical indications, relevant medical history, and any previous imaging results.
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