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How do I fill this out?
To fill out this form, you will need to provide patient details, insurance information, and the specific radiology exam required. Follow the instructions given in the file for each type of examination. Ensure all required fields are completed accurately.
How to fill out the Patient Referral Form and Instructions?
1
Enter patient details, including name, address, and contact information.
2
Provide insurance carrier and authorization number.
3
Specify the radiology exam ordered and any special instructions.
4
Include the referring provider's information and signature.
5
Fax or call the respective location to schedule the appointment.
Who needs the Patient Referral Form and Instructions?
1
Patients who need to undergo radiology examinations.
2
Healthcare providers referring patients for imaging studies.
3
Radiology centers requiring patient information before appointments.
4
Insurance companies needing details for claim processing.
5
Administrative staff managing patient appointments and records.
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1
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What are the instructions for submitting this form?
To submit this form, you can call 704.442.4390 to schedule an appointment, or fax the orders and a copy of patient's insurance card to 704.334.7837. For more information on the outpatient centers, visit www.carolinasimagingservices.com. Ensure the form is filled out completely before submission.
What are the important dates for this form in 2024 and 2025?
The form can be used throughout the year for scheduling radiology appointments. Ensure to check with your healthcare provider for any specific deadlines or required submission dates.
What is the purpose of this form?
The purpose of this form is to collect essential patient and examination details for radiology appointments. It ensures that healthcare providers have all necessary information for accurate diagnosis and treatment. Additionally, the form streamlines the process of scheduling and preparing for various radiology exams.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: Enter the full name of the patient.
- 2. Address: Provide the patient's complete address.
- 3. City: Enter the patient's city of residence.
- 4. State: Provide the state where the patient resides.
- 5. Phone: Enter the patient's contact phone number.
- 6. DOB: Provide the patient's date of birth.
- 7. ICD10 Code: Enter the ICD10 code for the diagnosis.
- 8. Insurance Carrier: Provide the name of the patient's insurance carrier.
- 9. Insurance Auth. #: Enter the insurance authorization number.
- 10. Exam Ordered: Specify the radiology exam ordered.
- 11. Clinical Information and Special Instructions: Provide any relevant clinical information and special instructions for the exam.
- 12. Referring Provider (print): Print the name of the referring provider.
- 13. Referring Provider Signature: Obtain the referring provider's signature.
- 14. Scheduling Confirm. #: Enter the scheduling confirmation number.
- 15. Practice Name: Provide the name of the referring provider's practice.
- 16. Date Ordered: Enter the date the referral was ordered.
What happens if I fail to submit this form?
Failing to submit this form can result in delays or cancellation of radiology appointments. Ensure all fields are accurately filled out and the form is submitted on time.
- Appointment Delays: Your radiology appointment may be delayed if the form is not submitted promptly.
- Cancellation: Failure to submit the form might lead to the appointment being canceled.
- Insurance Issues: Problems with insurance claims can arise if the form is not submitted correctly.
How do I know when to use this form?
- 1. Radiology Examination: When a patient needs an imaging study like MRI, CT scan, or ultrasound.
- 2. Insurance Authorization: To obtain authorization from the patient's insurance provider.
- 3. Clinical Information: To provide clinical details and special instructions for the exam.
- 4. Scheduling: To schedule the radiology appointment at the specified location.
- 5. Patient Preparation: To inform the patient of necessary preparations before the examination.
Frequently Asked Question
How do I fill out the Patient Referral Form?
Enter patient details, insurance information, and ordered exam details. Follow the instructions provided for each examination type.
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What information do I need to provide in the form?
Provide patient details, insurance information, the exam ordered, and any special instructions. Ensure all fields are accurately completed.
How do I schedule an appointment after filling out the form?
Call or fax the respective radiology location to schedule your appointment as indicated in the form.
Is there any preparation required for the examinations listed?
Yes, follow the detailed preparation instructions provided in the file for each type of radiology examination.
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What happens if I provide incorrect information on the form?
Double-check all information before submitting the form. Incorrect details may cause issues with scheduling and insurance claims.
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