3375 (F) 860-2026

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4.9 out of 5

30 votes

The document is a patient requisition form for Jefferson Radiology, detailing the necessary information and instructions required prior to scheduling imaging exams. It includes sections for patient demographics, insurance details, specific exam requests, anatomical areas of focus, and preparation instructions for various imaging procedures such as CT scans, MRIs, ultrasounds, and nuclear medicine. Additionally, it provides contact information for scheduling appointments and directions to multiple locations.

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Click ‘Get Form’ to open the 3375 (F) 860 in the editor.
Begin by entering the patient's name, date of birth, and weight in the designated fields. Ensure accuracy as this information is crucial for scheduling.
Fill in the contact numbers and indicate if the patient has claustrophobia by selecting 'Yes' or 'No'.
Provide insurance details including primary and secondary insurance names along with their respective ID numbers.
Complete the authorization sections as required, ensuring that all necessary authorizations are obtained prior to the appointment.
Specify the exam requested and list any signs or symptoms using ICD-10 codes. Be detailed to avoid issues with insurance claims.
Select the anatomical area and procedure type from the options provided, ensuring you check all relevant boxes.
Finally, have the referring MD print their name and sign where indicated before submitting the form.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (30 Votes)
2015	4.4 Satisfied (35 Votes)

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