Fillable Desert Radiology to OBTAIN AUTH

Fill Online, Printable, Fillable, Blank Desert Radiology to OBTAIN AUTH Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Desert Radiology to OBTAIN AUTH

On average this form takes 10 minutes to complete

The Desert Radiology to OBTAIN AUTH form is 1 page long and contains:

  • 0 signatures
  • 23 check-boxes
  • 29 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FOR DIAGNOSTIC MAMMO ONLY!!
Mark locaon of concern
Mammography:
Mammo SCREENING or Mammo DIAGNOSTIC w/ US (as needed, per paent symptoms)
Mammo SCREENING w/follow-up DIAGNOSTIC w/ US (as needed)
Mammo DIAGNOSTIC w/ US (as needed)
Other Women's Imaging
Breast US ______________________________________________________________________ Bilateral Le Right
Breast MRI w/ & wo ____________________________________________________________________________________
Ultrasound Other (specify) ________________________________________________________________________________
Breast Biopsy STEREOTACTIC ______________________________________________________________________________
Breast Biopsy US Guided _________________________________________________________________________________
Breast Biopsy MRI ______________________________________________________________________________________
DEXA ____________________________________________________________________________ ADD Vertebral Height
X-RAY (walk-in basis only, No Appointments) ______________________________________________________________________
Paent Name____________________________________________________________________________ DOB_________________________
Ph___________________________________ Cell Ph ____________________________________ Work/Alt ____________________________
Primary Ins______________________________________________________________ Policy #______________________________________
Authorizaon #______________________________________________________________
History / Symptoms (required)______________________________________________________________________________________________
ICD-10 / Diagnosis ____________________________________________________________________________________________________
Referring Physician __________________________________________________________________________________________________
Ph ___________________________ Fx ___________________________ CC Physician ___________________________________________
Oce Contact __________________________________________ CALL REPORT_________________________
CD to Oce CD w/ Paent DICOM CD to Oce Other __________________________________
Your appointment is scheduled / Su cita está previsto:
Date/Fecha: ___________________________Time/Hora: ___________________________
Arrival Time/Hora de llegada
:____________________________________________
DATE OF ORDER:
Desert Radiology to OBTAIN AUTH
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Desert Radiology to OBTAIN AUTH

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document