MEDICAL IMAGING ORDER FORM

Practice Information Patient Information Practice Name: Patient Name:

Address line 1: Address line 1:

Address line 2: Address line 2:

Phone number: Phone number:

Fax number: Email:

Practice Information

Provider Name: NPI:

ORDER DETAILS

Test Name: Diagnosis: CPT Code: ICD 10: Order date: Priority: Additional Note:

Imaging Facility Detail

Facility Name: Email: Fax: Phone number: Address line 1: Address line 2:

Order Expiration Date: 07/20/2020.

This imaging order is no longer medically necessary after the expiration date.

Report Instructions: Please provide the patient with a copy of the report. Fax additional copy to (214) 304- xxxxx

Electronically signed by:

Date signed: