MRI PA Patient Request Form

4. Treatments Already Tried (Check all that apply. Approximate dates if necessary)

Rows	Select if Tried	Date(s) (Mo/Yr)	For how long?	Where or Which Medication?
Physical Therapy
Chiropractic Care
Home Exercise Program
Pain Medications
Anti-Inflammatory Medications
Muscle Relaxers
Steroid Injections
Surgery
Other

5. Previous Imaging

6. Red Flag Symptoms (Check all that apply)
7. Special Considerations for MRI
Important Notice:
Seeds of Health Primary Care does not bill insurance for visits, imaging, or procedures. Prior authorizations are offered as a separate service upon patient request. In some cases, cash-pay MRI pricing may be faster, less expensive, and avoid insurance delays. We can provide referrals for these options upon request if you would like to bypass the prior authorization process. Completion of this form is not a guarantee that your insurance will approve the imaging request.
Patient Signature
Date

MonthDayYear
Date
Should be Empty:

Prior Authorization Information Form