855 202 0879-2026

1. Click ‘Get Form’ to open the 855 202 0879 document in the editor.
2. Begin by filling in the patient's name, date of birth, and sex in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Enter the patient’s phone number and the referring physician's name. This helps streamline communication regarding the exam.
4. In the clinical history section, provide a detailed reason for the exam. Avoid vague terms like 'Rule Out' or 'Probable' to ensure medical necessity is clear.
5. Select the appropriate exam type from the list provided, such as General X-Ray or MRI. Mark all relevant options clearly.
6. If applicable, indicate whether I.V. contrast is needed and if anesthesia is required by checking the corresponding boxes.
7. Finally, ensure that a physician signature is included along with the date and time before submitting your form.

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