MRI Order Form
Scott Chiropractic
Patient FIRST Name
*
Patient LAST Name
*
Patient Address
*
Street Address
Street Address Line 2
City
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Patient Phone
*
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Patient Email
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Patient Date of Birth
*
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Month
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Day
Year
Date
Patient Gender
*
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MedPay Billing Information
Insurance Company
*
Claim Number
*
Name of Adjuster
Adjuster Phone Number
Legal Information
Law Firm
*
Attorney Name
Attorney Phone
*
Please enter a valid phone number.
Exam
Date of Injury
*
/
Month
/
Day
Year
Date
Type of Exam
*
Cervical
Lumbar
Thoracic
Craniocervical Junction
Sacrococcygeal/SIJ
Other
Scan
MRI
Diagnosis
*
Please attach Clinical Notes
*
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PDF 2 (if needed)
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PDF 3 (if needed)
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Submit
Provider Name
*
Provider
Mark Scott DC
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)
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