Breast imaging referral form 2026

The document is a Breast Imaging Referral Form from Harrison Imaging Centers, providing essential information for patients regarding their appointments for breast imaging services. It includes details such as appointment scheduling, required documents, patient information, and specific imaging services offered at various locations. Additionally, it outlines preparation instructions for different types of imaging procedures and emphasizes the importance of medical necessity coding for insurance purposes.

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Click ‘Get Form’ to open the breast imaging referral form in the editor.
Begin by entering the appointment date and check-in time in the designated fields. Ensure accuracy for a smooth visit.
Select your preferred location from Silverdale, Port Orchard, or Poulsbo by checking the appropriate box.
Fill in the date of referral and print the referring provider's name. Remember to include their signature in the required section.
Complete patient information including name, gender, date of birth, and best contact number. This ensures proper identification and communication.
Provide insurance details and authorization number if applicable. This is crucial for billing purposes.
Indicate any previous films and whether the patient has implants by selecting 'Yes' or 'No'.
Choose the necessary screening or diagnostic services required by marking the relevant options on the form.

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Versions	Form popularity	Fillable & printable
2023	4.7 Satisfied (45 Votes)
2018	4.8 Satisfied (45 Votes)
2016	4.8 Satisfied (60 Votes)
2015	4.8 Satisfied (208 Votes)
2015	4.9 Satisfied (57 Votes)
2014	4.8 Satisfied (125 Votes)
2014	4.8 Satisfied (62 Votes)
2014	4.8 Satisfied (62 Votes)

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Do I need a Dr. script for a mammogram?

Did you know you dont need a referral, prescription or order form from your doctor to get a mammogram? Women over 40 who are not experiencing symptoms can make an appointment for their annual mammogram on their own. Annual mammograms are the best tool for early detection of cancer.

What is a red flag referral to the clinic?

Refer as red flag for cancer if they are: - aged 30 and over and have an unexplained (see note below) lump with or without pain or - aged 50 and over with any of the following symptoms in one only: - discharge - retraction - Other changes of concern.

Can you self refer a mammogram?

You wont usually be invited for screening once youre over 70. But you can refer yourself for a mammogram by contacting your local screening unit directly. You may be offered a mammogram once a year if youre under 50 and have a higher-than-normal risk of developing cancer.

Can I refer myself for a mammogram?

If you think you should have screening, but you are not invited automatically, talk to your GP surgery, or call or email your local screening service to ask for an appointment.