Scheduling an Appointment

The following information is necessary when scheduling an appointment with our out-patient imaging centers.
 

  • Referring Physician's Full Name
  • Referring Physician's Telephone Number
  • Patient's Full Name
  • Patient's Date of Birth
  • Patient's Social Security Number
  • Patient's Daytime Telephone Number
  • Insurance Carrier
  • Authorization Number
  • Procedure to be Scheduled
  • Diagnosis

Patient Referral Form

 

Supporting Information

Upon scheduling your patient with one of our out-patient imaging centers, please fax the following items to the appropriate office:
 

  • Patient Demographic information (Patient Registration Form)
  • Patient's Insurance Card(s) - (front and back)
  • Patient's signed Medical Release Form
  • Medical Reports (i.e. CT, PET, CXR, CEA Level, Pathology Report)
  • Physician's Prescription (orders)