Edit, Download, and Sign the Medical Imaging Order Form
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How do I fill this out?
To fill out this form, ensure all patient and ordering physician information is provided accurately. Be sure to select the correct imaging procedures required. Follow the preparatory instructions given for specific tests.
How to fill out the Medical Imaging Order Form?
1
Enter patient personal details including name and SSN.
2
Provide diagnosis, symptoms, and pre-authorization number.
3
Specify the type of imaging procedure required.
4
Include the ordering physician's name and signature.
5
Fax the completed form to the provided fax number.
Who needs the Medical Imaging Order Form?
1
Physicians needing to schedule diagnostic imaging for patients.
2
Patients requiring various types of imaging for medical reasons.
3
Medical office staff responsible for arranging patient imaging appointments.
4
Insurance companies requiring pre-authorization for imaging procedures.
5
Healthcare institutions tracking patient diagnostic procedures.
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1
Open the form on PrintFriendly.
2
Click on the fields that need editing.
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4
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Share or print the edited form.
What are the instructions for submitting this form?
Submit the completed Imaging Order Form via fax to 850.607.7553 or email to the scheduling office. Ensure all required fields are filled out accurately. Contact the office at 850.696.4200 for any additional questions.
What are the important dates for this form in 2024 and 2025?
This form is revised on 2/14. Ensure to follow the provided preparatory instructions and schedule imaging within the validity dates.
What is the purpose of this form?
The purpose of this form is to facilitate the ordering and scheduling of various diagnostic imaging procedures for patients. It collects all essential patient details, necessary imaging exams, and pertinent physician information to ensure accuracy in diagnostics and cost-effectiveness in medical imaging. Utilizing this form helps streamline communication between healthcare providers, medical staff, and patients to improve service delivery and imaging outcomes.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Full name of the patient undergoing the imaging procedure.
- 2. Diagnosis and Symptoms: Medical diagnosis and symptoms necessitating the imaging.
- 3. Scheduled Date and Time: The date and time of the scheduled imaging appointment.
- 4. SSN: Patient's Social Security Number.
- 5. Pre-Authorization #: Pre-authorization number required for insurance purposes.
- 6. XRAY: Section to specify X-Ray procedures required.
- 7. NUCLEAR MEDICINE: Section to specify nuclear medicine procedures needed.
- 8. ULTRASOUND: Section to detail required ultrasound procedures.
- 9. CT SCAN: Section to request CT scan details and necessary preparations.
- 10. PET/CT: Section for PET/CT imaging needs and preparatory instructions.
- 11. MRI: Section to specify MRI requirements and preparatory instructions.
- 12. BREAST HEALTH SERVICES: Section dedicated to breast health imaging services, including mammograms and biopsies.
- 13. Ordering MD Name, Signature: Field for the ordering physician's name and signature.
- 14. Office Phone: Contact number for the medical office scheduling the imaging.
What happens if I fail to submit this form?
Failing to submit this form results in delays in scheduling and conducting the necessary imaging procedures.
- Appointment Delay: Your imaging appointment cannot be scheduled without this form.
- Insurance Issues: Pre-authorization for imaging may not be approved without the form.
- Incomplete Medical Records: Failure to submit the form may result in incomplete medical documentation.
How do I know when to use this form?
- 1. Scheduling Imaging: Use this form to schedule any diagnostic imaging tests.
- 2. Insurance Pre-authorization: Submit this form for insurance pre-authorization of imaging services.
- 3. Medical Record Keeping: Ensure proper documentation and communication within healthcare providers.
Frequently Asked Questions
How do I fill out the Imaging Order Form?
Fill out patient information, select the required imaging procedures, provide physician details, and fax the form.
Can I edit the Imaging Order Form on PrintFriendly?
Yes, you can edit the form using PrintFriendly’s PDF editor by clicking on the fields and entering your information.
How do I schedule an imaging appointment?
Complete the form with the necessary details and fax it to the provided number to schedule an appointment.
Can I sign the Imaging Order Form on PrintFriendly?
Yes, you can use the signature tool on PrintFriendly to sign the form digitally.
How can I share the completed Imaging Order Form?
You can share the form via email or a shareable link on PrintFriendly.
What is required to complete the Imaging Order Form?
You need patient information, imaging procedure details, physician’s information, and a signature.
Is the Imaging Order Form available for download?
Yes, after completing and editing, you can download the form from PrintFriendly.
What preparatory instructions are included in the form?
The form includes instructions like fasting before certain appointments or ensuring a full bladder.
Can insurance information be added to the form?
Yes, there is a section for pre-authorization numbers and related insurance details.
How do I save my edits on PrintFriendly?
After making all necessary edits, save the form to your device using the Save option.
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