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6135 SW 17th St., Topeka, KS 66615
(785) 6706760 | F: (785) 6706757
www.TopekaHospital.comPatient InformationRequest for Outpatient Imaging ServicesLast Name ___ First Name ___ Middle Name ___
Date
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How to fill out request for outpatient imaging
How to fill out request for outpatient imaging
01
Locate the outpatient imaging center where you will be receiving the imaging services
02
Obtain the necessary request form from your primary care physician or referring healthcare provider
03
Fill out the request form completely and accurately, providing all required information such as your personal details, the type of imaging needed, and the reason for the request
04
Make sure to include any relevant medical history or previous imaging results that may impact the imaging process
05
Submit the completed request form to the outpatient imaging center either in person or through the preferred method of communication
Who needs request for outpatient imaging?
01
Patients who have been referred by their primary care physician or another healthcare provider for specific imaging services
02
Individuals who are seeking diagnostic or screening imaging services for medical evaluation or monitoring purposes
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What is request for outpatient imaging?
Outpatient imaging request is a form submitted by a healthcare provider to authorize imaging procedures for patients receiving care outside of a hospital setting.
Who is required to file request for outpatient imaging?
Healthcare providers or physicians are required to file a request for outpatient imaging on behalf of their patients.
How to fill out request for outpatient imaging?
The request for outpatient imaging form must be completed with patient information, reason for the imaging procedure, and any pertinent medical history.
What is the purpose of request for outpatient imaging?
The purpose of the request for outpatient imaging is to ensure that patients receive necessary imaging procedures in an outpatient setting.
What information must be reported on request for outpatient imaging?
The request for outpatient imaging must include patient demographics, medical history, reason for imaging, and requested procedure details.
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