mobile x-ray order form
801-770-4814 - admin@medicalmi.com
DATE
*
-
Month
-
Day
Year
Date
WHO IS PLACING THIS REQUEST
*
Please Select
Home Health/Hospice
Assisted Living
Chiropractor
Podiatrist
Orthopaedic
Other Physician
Patient
HOW SOON DOES THE EXAM NEED TO BE COMPLETED
*
Please Select
Stat
Next Day
2-3 Days
Within 1 Week
Facility/Agency Name
*
Facility Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Report To
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Name
*
First Name
Last Name
Patient Phone Number
*
Number to Contact to Schedule Exam
Format: (000) 000-0000.
Address to Perform Exam
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient SSN
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Email
*
example@example.com
Ordering Physician
*
Ordering Physician NPI
*
Ordering Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Where Will This Exam Take Place?
*
Please Select
Facility
Residence
Facility Address
*
Street
Facility City
*
City
Patient Room/Bed
*
Number
Residents Address
*
Street
Residents City
*
City
BILLING INFORMATION
Who Will Be Billed AL/HH
*
Please Select
Bill Insurance
Bill Facility
Who Will Be Billed
*
Please Select
Bill Insurance
Cash Pay
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
Please Select
Aetna
Blue Cross/Blue Shield
Cigna
Humana
Medicaid
Medicare
Other
Medicare #
Medicaid #
Other Insurance
Address
ID #
Group #
Responsible Party Name
*
Responsible Party Phone
*
Responsible Party Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload a Photo of Your Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
FRONT
Cancel
of
Upload a Photo of Your Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
BACK
Cancel
of
SPECIAL INSTRUCTIONS
WHERE DID YOU HEAR ABOUT US?
X-RAY EXAM
TYPE OF X-RAY NEEDED
*
REASON FOR EXAM
*
PHYSICIANS SIGNATURE
*
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