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IMAGING PROCEDURE REQUEST APPOINTMENT LINE: (828) 2127021FAX: (833) 9581171MessinoCancerCenters.com/DiagnosticImagingPatient Name ___ SSN ___ DOB___ Home Phone # ___ Other Phone # ___ CD of Images

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How to fill out imaging procedure request

01

Obtain the necessary form for the imaging procedure request.

02

Fill out patient information including name, date of birth, and medical record number.

03

Specify the type of imaging procedure needed (e.g. MRI, CT scan, X-ray).

04

Provide relevant clinical history and reason for the imaging request.

05

Sign and date the request form before submitting it to the imaging department.

Who needs imaging procedure request?

01

Patients who have been recommended to undergo imaging tests by their healthcare provider.

02

Healthcare providers who require imaging studies to aid in diagnosis and treatment planning.

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What is imaging procedure request?

Imaging procedure request is a formal request made by a healthcare provider to schedule a medical imaging test or procedure for a patient.

Who is required to file imaging procedure request?

Healthcare providers such as doctors, specialists, or radiologists are required to file imaging procedure requests.

How to fill out imaging procedure request?

To fill out an imaging procedure request, healthcare providers must provide patient information, reason for the imaging procedure, type of imaging required, and any relevant medical history.

What is the purpose of imaging procedure request?

The purpose of imaging procedure request is to facilitate the scheduling of medical imaging tests or procedures to aid in the diagnosis and treatment of patients.

What information must be reported on imaging procedure request?

Information such as patient demographics, medical history, reason for imaging, type of imaging requested, and referring provider information must be reported on an imaging procedure request.

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