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Breast & DEXA Imaging Request1720 Esplanade
Chico, CA 95926
O: 5308980500
F: 5308980533
halobreastcare.complete see instructions on back
Patient Name: ___
Home Phone: ___ DOB: ___
ICD/Diagnosis/Indications:___Breast
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How to fill out 1179qhbcc-breast dexa imaging request
How to fill out 1179qhbcc-breast dexa imaging request
01
Obtain the 1179qhbcc-breast dexa imaging request form from the appropriate medical facility.
02
Fill out the patient's personal information including name, date of birth, and medical record number.
03
Indicate the reason for the breast dexa imaging request in the designated section.
04
Include any relevant medical history or information that may impact the imaging results.
05
Ensure that the form is signed and dated by the requesting healthcare provider.
Who needs 1179qhbcc-breast dexa imaging request?
01
Patients who have been prescribed breast dexa imaging by their healthcare provider.
02
Healthcare providers who are requesting a breast dexa imaging to assist in diagnosis and treatment planning.
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What is 1179qhbcc-breast dexa imaging request?
1179qhbcc-breast dexa imaging request is a form used to request a breast DEXA imaging procedure.
Who is required to file 1179qhbcc-breast dexa imaging request?
Healthcare providers or patients may be required to file 1179qhbcc-breast dexa imaging request depending on the specific medical situation.
How to fill out 1179qhbcc-breast dexa imaging request?
1179qhbcc-breast dexa imaging request should be filled out with patient information, reason for the request, and any relevant medical history.
What is the purpose of 1179qhbcc-breast dexa imaging request?
The purpose of 1179qhbcc-breast dexa imaging request is to document the need for a breast DEXA imaging procedure.
What information must be reported on 1179qhbcc-breast dexa imaging request?
Information reported on 1179qhbcc-breast dexa imaging request may include patient name, date of birth, referring physician, and reason for the procedure.
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