CT Scan Prior Authorization Information Form

Prior Authorization Information Form

CT Scan
Patient Information
Name

First NameLast Name
Email
example@example.com
DOB

MonthDayYear
Date
Date Submitted

MonthDayYear
Date
What area of your body will the CT scan focus on?

Head/BrainNeckChest/LungsAbdomen/PelvisSpineOther
Do you know if you provider ordered the scan with or without contrast?

With ContrastWithout ContrastBoth/Not sure
What Symptoms are you having that led to this test being ordered?
How long have you had these symptoms?

Less than 1 week1-4 weeks1-3 monthsMore than 3 months
Have your symptoms been getting worse?

YesNoAbout the sameType option 4
Have you had any imaging (X-ray, CT, MRI, ultrasound) for this problem before?

No previous imagingYes - I have had previous imaging
Date(s) and type(s) of imaging:
Have you tried any treatments or medications for this problem?

Yes - tried treatments or medication(s)No treatments tried
Please provide details of the treatments or medications tried in the past.
Do you have a history of cancer in the area being imaged?

Yes - history of cancer in this areaNo
What type of cancer was it?
Have you had any surgeries in the area being imaged?

Yes - had surgery(s) in this areaNo
What type of surgery did you have?
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.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Prior Authorization Information Form

Patient Information