Facility: Mirage Imaging Center Date of Request:
Sender's Name: Sender's Email:
1. Patient Information (Please fill out completely)
Name: Address:
Birthdate: City/State/Zip:
SSN: Male Female
Home Phone: Work Phone:
2. Case Type (Please Check)
Attorney Lien Med Pay Workers Comp.
Cash PPO Authorized
Green Lien Private Insurance Not Authorized
3. Insurance Information (Please fill out completely)
Carrier Name: Claim#:
Address: Group#:
City/State/Zip: Adjuster:
Employer: Adjuster Phone:
Address: Employer Phone:
City/State/Zip:    
4. Attorney Information (Please fill out completely)
Attorney Name: Phone:
Address: Fax:
City/State/Zip:  
5. Referring Doctor:
Name: Phone:
Address: Fax:
City/State/Zip:  
6. Medical History:
Date of Injury: Previous Surgery: Yes No
Metal Worker Yes No What body part:
Allergies: Previous MRI / X-Ray: Yes No
Height: What body part:
Weight: Diagnosis:
Chief Compliant:
7. MRI Requirements:
70551 Brain 73221 Elbow R  73221 Elbow L
70553 Brain w/Contrast 73221 Wrist R    73221 Wrist L
72141 Cervical Spine 73220 Hand R   73220 Hand L
72146 Thoracic Spine 73721 Hip R       73721 Hip L
73221 Shoulder R 73221 Shoulder L 73721 Knee R   73721 Knee L
Other: w/Contrast 73721 Ankle R   73721 Ankle L
  73720 Foot R     73720 Foot L

     

 

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