Imaging Prior Authorization Request
Submit your request for prior authorization of imaging procedures with all required details.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Insurance Provider Name
*
Insurance Member ID (Do not enter sensitive government-issued numbers)
*
Ordering Physician Name
*
First Name
Last Name
Ordering Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider or Facility Name
Requested Imaging Procedure
*
Please Select
MRI
CT Scan
Ultrasound
X-Ray
PET Scan
Other
CPT/Procedure Code (if applicable)
Clinical Indication/Reason for Imaging
*
Urgency of Request
*
Routine
Urgent
Stat
Previous Relevant Imaging Performed?
*
Yes
No
Upload Supporting Documentation (e.g., clinical notes, previous imaging reports)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Request
Should be Empty: