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MRI and CT Head and MRI Spine Imaging Request M - evicore

MRI and CT Head and MRI Spine Imaging Request M - evicore 2026

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The document is a request form for MRI imaging of the spine, specifically for cases of known or suspected spine trauma. It outlines the necessary information required from the ordering provider and patient, including personal details, clinical history, symptoms, and previous treatments. The form emphasizes the importance of providing complete and accurate information to avoid delays in processing the request. Additionally, it includes confidentiality notices regarding HIPAA regulations.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Ordering Provider' section. Enter the first name, middle initial, date of birth, gender, and contact information for both the patient and provider.
In the 'Procedure' section, check all applicable CPT codes for MRI C-Spine, T-Spine, and L-Spine. Ensure you include any relevant diagnosis or ICD-10 codes.
Provide clinical information by answering questions regarding symptoms, treatment history, and any previous imaging results. This is crucial for accurate processing.
Complete the 'Submitter' section with your name, title, and signature. Make sure to date the form before submission.

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