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This document is a procedure request form for imaging services, including CT and PET scans, at Cancer & Blood Specialists of Arizona. It collects patient information, insurance details, previous studies, and specific imaging requests, along with preparation instructions for various types of scans.
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How to fill out imaging procedure request
How to fill out imaging procedure request
01
Begin by entering the patient's full name at the top of the form.
02
Fill in the patient's date of birth and contact information.
03
Specify the type of imaging procedure needed (e.g., X-ray, MRI, CT scan).
04
Provide the clinical indication for the imaging and any relevant history.
05
Include the referring physician's name and contact details.
06
Specify the date and time for the procedure if required.
07
Sign and date the request form.
Who needs imaging procedure request?
01
Referring physicians or healthcare providers.
02
Patients who require diagnostic imaging.
03
Medical facilities that need to document imaging requests.
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What is imaging procedure request?
An imaging procedure request is a formal document initiated by a healthcare provider to order diagnostic imaging tests, such as X-rays, MRIs, or CT scans for a patient.
Who is required to file imaging procedure request?
Typically, healthcare providers such as physicians, specialists, or other qualified medical professionals are required to file imaging procedure requests on behalf of patients.
How to fill out imaging procedure request?
To fill out an imaging procedure request, the healthcare provider needs to complete the required form with patient details, the type of imaging requested, relevant medical history, and the clinical reason for the request.
What is the purpose of imaging procedure request?
The purpose of an imaging procedure request is to ensure that appropriate imaging tests are performed for diagnostic and treatment planning, enabling healthcare providers to make informed decisions about patient care.
What information must be reported on imaging procedure request?
The information that must be reported includes the patient's identifying information, type of imaging requested, referring physician details, clinical indications, and any necessary medical history.
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