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?

Other
Do you know if you provider ordered the scan with or without contrast?
What Symptoms are you having that led to this test being ordered?
How long have you had these symptoms?
Have your symptoms been getting worse?
Have you had any imaging (X-ray, CT, MRI, ultrasound) for this problem before?
Date(s) and type(s) of imaging:
Have you tried any treatments or medications for this problem?
Please provide details of the treatments or medications tried in the past.
Do you have a history of cancer in the area being imaged?
What type of cancer was it?
Have you had any surgeries in the area being imaged?
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
Date

MonthDayYear
Date
Should be Empty:

Prior Authorization Information Form