Form - Women and Infants Hospital of Rhode Island 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and phone number in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Indicate the patient's weight and whether they are pregnant or trying to conceive by selecting 'Y' or 'N'.
4. Fill in the primary language and whether an interpreter is needed. This ensures effective communication during the appointment.
5. Provide insurance details, including plan number and pre-authorization if required. This information is essential for billing purposes.
6. In the 'Reason for Study/Symptoms' section, clearly describe any symptoms or reasons for the imaging request.
7. Select the appropriate imaging services required by checking the relevant boxes under 'Breast Imaging', 'General Radiology', and 'Ultrasound'.
8. Complete the ordering physician's details, including their signature and office number, ensuring all fields are filled out accurately.

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