Advanced Imaging Referral Form - nyrpcom 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and contact information, including their home phone and cell number. Ensure accuracy for effective communication.
3. Fill in the exam date and time, along with any prior studies that may be relevant. This helps in providing comprehensive care.
4. Complete the clinical history section, including ICD codes if applicable. Don’t forget to include bun/creatinine levels if required for contrast exams.
5. Provide referring physician details, including their name, phone number, address, and NPI number. Ensure all clinicians are registered as ordering providers.
6. Select the type of imaging required (CT Scan, MRI, etc.) and specify any special instructions or contrast requirements.
7. Review all entered information for accuracy before saving or sending the form. Utilize our platform’s features to sign electronically if needed.

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