XRC Thumbnails

Patient Information
Patient Name:
Responsible Party Name:
Responsible Party Address:
Patient's Date of Birth:
SSN:
Patient Contact Information
Number: Type:
Number: Type:
Number: Type:

Insurance Information
Primary Insurance
Company:
Group #:
Plan #:
Policy Holder Name:
Policy Holder Birthdate:
Secondary Insurance
Company:
Group #:
Plan #:
Policy Holder Name:
Policy Holder Birthdate:

Exam Information
 
Exam(s) Requested:
Diagnosis / ICD-9 Codes:
Special Instructions:
Preferred Time/Date Exam:
Ordering Physician:
Office Telephone:

  1. Please FAX a signed physician order to 574-272-8617.
  2. We will contact your patient & arrange scheduling details.
  3. If pre-certification is required, we will call your office.