MRI Referral Form
UCHC - Washington
Patient FIRST Name
*
Patient LAST Name
*
Patient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
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California
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District of Columbia
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
example@example.com
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Gender
*
Male
Female
Other
Billing Information
Insurance Company
*
Claim Number
*
Name of Adjuster
Adjuster Phone Number
Legal Information
Law Firm
*
Attorney Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Attorney Name
Exam
Type of Exam
*
Cervical
Lumbar
Thoracic
Left Hip
Right Hip
Left Shoulder
Right Shoulder
Left Wrist
Right Wrist
Left Knee
Right Knee
Craniocervical Junction
Sacrococcygeal/SIJ
Other
Date of Injury
*
/
Month
/
Day
Year
Date
Scan
MRI
Diagnosis
*
Please attach Clinical Notes
*
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of
PDF 2 (if needed)
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of
PDF 3 (if needed)
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of
Submit
Provider Name
*
Provider
Dr. Kim, Woo
Other (Type in additional options box)
Today's Date
/
Month
/
Day
Year
Date
URC Admin Email
example@example.com
URC Company Name
Practice Name
Additional Information (optional)
Submit
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