Medical imaging exam request form - Intermountain Healthcare - intermountainhealthcare 2025

Get Form
Medical imaging exam request form - Intermountain Healthcare - intermountainhealthcare Preview on Page 1

Here's how it works

01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Medical imaging exam request form - Intermountain Healthcare

Form edit decoration
9.5
Ease of Setup
DocHub User Ratings on G2
9.0
Ease of Use
DocHub User Ratings on G2
  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling in the 'Appointment Details' section. Select the clinic location and enter the date and time for the appointment.
  3. In the 'Patient Information' section, provide the patient's name, date of birth, contact numbers, insurance company, and email address.
  4. Next, complete the 'Referring Physician Information' by entering the physician's name, office phone number, and signature with date and time.
  5. Indicate any sedation requirements by checking the appropriate box under 'Sedation recommended for'.
  6. Clearly state the reason for the imaging procedure in the designated area. Be specific to ensure proper examination.
  7. Select the type of exam required from options provided under 'Exam Type', ensuring all relevant boxes are checked.
  8. Finally, review all entries for accuracy before saving or sending your completed form through our platform.

Start using our platform today to streamline your medical imaging requests effortlessly!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us
Colorado-based SCL Health and Intermountain Health merged in 2022. The combined system employs more than 64,000 people.
Your image files are typically stored at the facility where you had your exam. When you request your medical images, you will need to sign a release form. The images will typically be available as: printed photos (also known as radiology films).
To pursue an entry-level role as a radiologic technician, youll typically need at least an associate degree with training in anatomy, radiographic imaging and physics, procedures, and positioning, as well as related knowledge of patient care skills.
Intermountain completed a merger with SCL Health on April 1, 2022, expanding the healthcare systems docHub into Colorado, Kansas, and Montana. Intermountain changed its name from Intermountain Healthcare to Intermountain Health in 2023.
For magnetic resonance imaging (MRI): Depending on whether contrast dye is used, hospitals charge anywhere between $1,800 and $3,000 plus other costs. At IMI, our prices range between $1,400 and $1,500.