Diagnostic Imaging Order and Referral Form
This file contains the diagnostic imaging order and physician referral forms for various Legacy Medical Centers. It includes information for scheduling appointments, as well as preparation instructions for different types of imaging studies. Ideal for healthcare providers and patients seeking imaging services.
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How do I fill this out?
To fill out this form, start by entering the patient's information, including their name, date of birth, and reason for examination. Then, specify the ordering physician and the relevant insurance information. Finally, choose the appropriate diagnostic tests required and provide any necessary signatures.
How to fill out the Diagnostic Imaging Order and Referral Form?
1
Fill in the patient’s personal and medical information.
2
Indicate the reason for the imaging exam and any relevant codes.
3
Select the specific tests required from the options provided.
4
Provide the referring physician's contact details.
5
Sign and date the form before submission.
Who needs the Diagnostic Imaging Order and Referral Form?
1
Physicians needing to refer patients for imaging services.
2
Patients requiring diagnostic imaging for health assessments.
3
Administrative staff scheduling imaging appointments.
4
Insurance representatives verifying coverage for imaging.
5
Medical specialists reviewing imaging results and ordering additional tests.
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Select the 'Edit' option to access the editing tools.
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What are the instructions for submitting this form?
To submit the completed form, fax it to the appropriate imaging center based on the state. For Oregon, use 503-413-8899, and for Washington, use 360-487-1822. Alternatively, you may deliver the form in person at any Legacy Medical Center location.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, ensure that any imaging orders are submitted timely based on the patient's scheduled appointments. Relevant deadlines may apply if pre-authorization is required by insurance providers. Check with your physician for specific dates related to ordered imaging procedures.
What is the purpose of this form?
The purpose of this form is to provide a standardized method for ordering diagnostic imaging studies. It ensures that patients receive the necessary imaging services promptly and that physicians have a clear record of referrals. This form facilitates communication between healthcare providers and imaging departments, improving patient care delivery.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for the patient's name, date of birth, and appointment details.
- 2. Symptoms/Reason for Exam: Captures the reason for the imaging request, including ICD-9/10 codes.
- 3. Ordering Physician: Details about the physician requesting the imaging, including contact information.
- 4. Diagnostic Tests: Lists imaging options such as MRI, CT, and ultrasound for the physician's selection.
- 5. Signature: Requires the physician's signature for verification and authorization of the request.
What happens if I fail to submit this form?
If you fail to submit this form, your imaging appointment may be delayed or canceled. Not providing necessary information can result in incorrect referrals, causing complications in patient care. It is crucial to ensure the form is completed and submitted accurately.
- Delays in Appointment: Incomplete forms can prevent timely scheduling of necessary imaging.
- Insurance Issues: Missing or incorrect information may lead to insurance complications.
- Referrals Errors: Inaccurate information can cause miscommunication between healthcare providers.
How do I know when to use this form?
- 1. Routine Checkups: When a physician orders imaging as part of annual health evaluations.
- 2. Follow-up Exams: To track progress after treatment and evaluate patient response.
- 3. Pre-Operative Evaluations: Before surgery, imaging may be needed to assess condition.
Frequently Asked Questions
How do I fill out this form?
Begin by entering the patient's information followed by the required imaging tests.
Can I save my changes to the PDF?
You can download the PDF after editing, but saving on the site is not currently available.
What if I make a mistake on the form?
You can easily edit the PDF and correct any errors before downloading.
Is there a way to print the PDF?
Yes, after editing, you can print the PDF directly from PrintFriendly.
How do I share the PDF with someone?
Use the share feature on PrintFriendly to send the PDF via email or link.
Can I sign the PDF electronically?
Yes, PrintFriendly allows you to add an electronic signature to your PDF.
What types of images can I request?
You can choose from various imaging options listed in the form, such as MRI and CT scans.
Is the form valid for all Legacy Medical Centers?
Yes, it is applicable across all listed Legacy Medical Centers.
How will I receive results?
Results can be sent via fax or communicated directly, as indicated on the form.
What should I do with the completed form?
Submit the completed form to the relevant imaging department via fax or in person.
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