Pre-Authorization Request Form Online - Lakeside MRI

PRE-AUTHORIZATION REQUEST FORM

PATIENT : __________________________ DOB: ___________ STUDY: ______________________ CPT: _______ REFERRING PHYSICIAN: _______________________ TAX ID: _________________ NPI: ____________________ PATIENT'S DIAGNOSIS? _____________________________________________ ICD-9: ____________________

In order for LAKESIDE MRI & DIAGNOSTIC CENTER to assist your office in obtaining Authorization/Notification for the above patient's procedure, we must have your permission and additional clinical information.

1. Most recent contact with physician. Date: ____________________ Type: ___________________________ (please indicate office visit, hospital visit, telephone with nurse, telephone with physician, etc.)

2. Has the patient suffered recent injury or trauma? (If yes, indicate date of injury) _________________________________________________________________________________________

3. Patient's symptoms (ex. pain, numbness, radiculopathy/weakness; include duration, frequency and intensity) _________________________________________________________________________________________

4. Clinical signs and positive tests demonstrated: _________________________________________________________________________________________

5. Is the patient taking any medications for this condition? How long? Has the pt shown any improvement? ________________________________________________________________________________________

6. What is the physician suspecting or ruling out with the requested study? ________________________________________________________________________________________

7. Has the patient received treatment for the above symptoms (duration and type)? ________________________________________________________________________________________

8. Has the patient had physical therapy or home exercise program? How long? _________________________________________________________________________________________

9. Any previous relevant testing including results (labs, diagnostic imaging, or other test) _________________________________________________________________________________________

10. Is there any relevant family history related to the diagnosis or suspected diagnosis? ________________________________________________________________________________________ PHYSICIAN SIGNATURE: _____________________________

PLEASE COMPLETE AND RETURN VIA FAX TO 281-554-8407

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