DIAGNOSTIC SCHEDULING REQUEST FORM -- ON-LINE SUBMISSION

Items in RED are required

Assignment Type:

MRI MRA CT X-RAY   Select Contrast Type: No Contrast With Contrast Both

Claimant Speaks:

Spanish Creole Other   

<--- If OTHER languageplease       specify....     

Submission Date:

 Date Needed By:

Preliminary Aging?:

NO YES   Recond Opinion Request: NO YES

Your Case/Claim #:

Authorization Length:

1 Week 2 Weeks 3 Weeks 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 1 Year Indefenite Other      <<Select one, if Other explain here --->

Requester Title:

Case Manager Adjuster Provider Claimant Lawyer Other  <<Select one, if Other explain here --->

CLIENT INFORMATION

Client/Billing Goes To
(Name of Ins. Co.):

Client/Billing Address:

Client/Billing City:

Client/Billing State:

Client/Billing ZIP:

Client Phone:

Extension:

Client FAX:

ADJUSTER INFORMATION

Contact Person Y/N: 

Adjuster Name:

Adjuster’s Company Name:

Adjuster Phone:

Extension:

Adjuster FAX:

Adjuster E-mail:

CASE MANAGER INFORMATION

Contact Person Y/N: 

Case Manager Name:

Case Manager’s Company Name:

Case Manager Phone:

Extension:

Case Manager FAX:

Case Manager E-mail:

CLAIMANT INFORMATION

Claim/Case Number:

Claimant Name:

Claimant DOB:

Claimant SSN:

Claimant Street Address:

Claimant City:

Claimant State:

Claimant ZIP:

Claimant Primary Phone:

Claimant Secondary Phone:

Claimant Type of Injury:

Claimant Date of Injury:

Claimant Measurements:

Height ---  Feet:   

Inches:

Weight:

Claimant Has Wheelchair:

Y/N: 

Claimant Emergency Contact:

Claimant Emerg. Contact Relation:

Claimant Emergency Contact Phone:

Claimant Lives in:

Apartment

Floor # 

House: 

# of Floors 

CLAIMANT’S EMPLOYER

Employer Name:

Employer Street Address:

Employer City:

Employer State:

Employer ZIP:

Employer Contact Name:

Employer Contact Phone Number:

Extension:

Employer Contact FAX Number:

REQUIREMENTS INFORMATION

Additional Comments / Requirements