MRI PA Patient Request Form

Prior Authorization Information Form

MRI
Patient Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Todays Date

MonthDayYear
Date
Area of Body for MRI

Brain/HeadBrain/Cervical SpineThoracic SpineLumbar SpineShoulder (Right/Left)Knee (Right/Left)Hip (Right/Left)Abdomen PelvisOther
2. Reason for MRI (Select all that apply)

New injury or accidentPersistent pain despite treatmentNeurological Symptoms (numbness, tingling, weakness)Headaches or vision changesMass, lump or swellingAbnormal finding on previous test (X-ray, CT, ultrasound)Follow-up after surgery or treatmentOther
3. Symptom Details
When did symptoms start?

MonthDayYear
Date
Are symptoms getting:

WorseBetterUnchanged
Any specific events that triggered symptoms?

YesNo
If yes, describe:

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

	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)

Sudden weakness or numbnessLoss of bladder function or bowel controlUnintentional weight lossFever with painHistory of cancer
7. Special Considerations for MRI

Claustrophobia requiring medication to be scannedPacemaker, defibrillator, or implanted deviceSurgical clips, metal fragments, or joint replacementsAllergy to MRI Contrast - GadoliniumPregnant or possibly pregnant
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

Clear
Date

MonthDayYear
Date
Should be Empty:

Prior Authorization Information Form