Get the free 18624HBCC-Breast DEXA Imaging Request Form

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Breast & DEXA Imaging Request1720 Esplanade Chico, CA 95926 O: 5308980500 F: 5308980533 halobreastcare.comPlease see instructions on back Patient Name: ___ Home Phone: ___ DOB: ___ ICD/Diagnosis/Indications:___Please

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How to fill out 18624hbcc-breast dexa imaging request

01

Obtain the 18624hbcc-breast dexa imaging request form.

02

Fill out the patient's details including name, date of birth, and contact information.

03

Specify the reason for the request and the requesting physician's information.

04

Provide any relevant medical history that may assist in interpreting the results.

05

Ensure all sections of the form are completed accurately and legibly.

06

Submit the completed form to the imaging center or healthcare provider as per their instructions.

Who needs 18624hbcc-breast dexa imaging request?

01

Patients who have been recommended breast dexa imaging by their physician for screening or diagnosis.

02

Healthcare providers who are requesting the imaging test to better evaluate their patient's breast health.

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What is 18624hbcc-breast dexa imaging request?

The 18624hbcc-breast dexa imaging request is a medical request for a breast DEXA imaging procedure.

Who is required to file 18624hbcc-breast dexa imaging request?

Healthcare providers and professionals who are authorized to order medical imaging procedures are required to file the 18624hbcc-breast dexa imaging request.

How to fill out 18624hbcc-breast dexa imaging request?

The 18624hbcc-breast dexa imaging request must be filled out with the patient's demographic information, medical history, referring provider details, and specific details related to the imaging procedure.

What is the purpose of 18624hbcc-breast dexa imaging request?

The purpose of the 18624hbcc-breast dexa imaging request is to assess and evaluate breast health for diagnostic or preventive purposes.

What information must be reported on 18624hbcc-breast dexa imaging request?

The 18624hbcc-breast dexa imaging request must include the patient's name, date of birth, medical record number, clinical indications for the imaging procedure, and any relevant medical history.

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