Get the free Imaging Procedure Request

This document is a request form for imaging procedures at Genesis Cancer and Blood Institute. It collects patient information, insurance details, and specifics about the type of imaging being requested, including CT and PET scans. The form also provides preparation instructions for patients.

How to fill out imaging procedure request

How to fill out imaging procedure request

1. Begin by obtaining the imaging procedure request form from your healthcare provider or the facility.
2. Fill in patient information, including full name, date of birth, and medical record number.
3. Specify the type of imaging procedure needed, such as X-ray, MRI, CT scan, or ultrasound.
4. Provide clinical details or symptoms that justify the need for the imaging procedure.
5. Indicate urgency level: routine, urgent, or emergent, if applicable.
6. Include the referring physician’s details, such as name, contact information, and signature.
7. List any prior imaging studies related to this request, if available.
8. Submit the completed form to the imaging department or appropriate facility.

Who needs imaging procedure request?

1. Patients requiring diagnostic imaging for evaluation of symptoms or conditions.
2. Referring physicians who need to assess a patient's health status.
3. Medical facilities that perform imaging procedures for patient care.
4. Insurance companies that may need documentation for approval of imaging services.

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What is imaging procedure request?

An imaging procedure request is a formal document that healthcare providers submit to request medical imaging services, such as X-rays, MRIs, or CT scans, for diagnosing or treating patients.

Who is required to file imaging procedure request?

Healthcare providers, including physicians and specialists, are required to file imaging procedure requests for patients to ensure proper diagnosis and treatment.

How to fill out imaging procedure request?

To fill out an imaging procedure request, the healthcare provider should provide patient information, specify the type of imaging needed, include clinical indications for the request, and ensure all required signatures are obtained.

What is the purpose of imaging procedure request?

The purpose of an imaging procedure request is to document the necessity of the imaging study, facilitate communication between healthcare providers, and ensure that the appropriate imaging studies are performed for diagnosis and treatment.

What information must be reported on imaging procedure request?

The information that must be reported includes patient demographics, clinical history, the type of imaging requested, the reason for the procedure, and the referring physician's information.