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RequiRed FOR AuTHORiZATiON
Patient Last Name ____________________________Patient First Name ___________________________Phone _______________________________________Date of Injury ________________________________Date of Birth _________________________________Insurance Name ______________________________Attorney Name (for PI) _______________________Attorney Phone (for PI) _______________________r Cash r Personal Injury (PI) r WC r PPO
Please see reverse for additional requirements
BakersfieldBellflowerBeverly HillsColtonCulver CityDowntown LAEncinoFullertonGlendaleLancaster
Mission ViejoRiversideSan BernardinoSan DiegoSherman OaksSun ValleyTorranceTustinWinnetka
LOcATiONs
EXPERTMRITechnology | Science | Evidence
TEL: (877) 674-8888 | FAX: (877) 370-5458 www.expertmri.com | [email protected]
For a list of requirements or to order more pads visit www.expertmri.com/requirements
Mu
scu
LOsk
eLe
TA
L
X-Ray L RAnkle
Elbow
Femur
Foot
Forearm
Hand
Hip
Humerus
Knee
Shoulder
Tibia/Fibula
TMJ
Wrist
Other ____________
cT L RWO iV
contrastWith iV contrast
Ankle
Elbow
Femur
Foot
Forearm
Hand
Hip
Humerus
Knee
Shoulder
Tibia/Fibula
TMJ
Wrist
Other ____________
MRi L RMulti
Positionsingle
PositionWO iV
contrastWith iV
contrastW/WO iV contrast Arthrogram
Ankle
Elbow
Femur
Foot
Forearm
Hand
Hip
Humerus
Knee
Shoulder
Tibia/Fibula
TMJ
Wrist
Other ______________________
BR
AiN X-Ray
Brain
cTWO iV
contrastWith iV contrast
Brain
Brain (TBI)
MRiWO iV
contrastWith iV
contrastW/WO iV contrast MR Angio
Brain
Brain (TBI)
BO
dy
X-Ray Abdomen
Chest
Neck Soft Tissue
Orbits
Paranasal Sinuses
Pelvis
Sella/Pituitary
Sternum
cTWO iV
contrastWith iV contrast
Abdomen
Chest
Neck Soft Tissue
Orbits
Paranasal Sinuses
Pelvis
Sella/Pituitary
Sternum
MRiWO iV
contrastWith iV
contrastW/WO iV contrast
Abdomen
MRCP
Chest
Neck Soft Tissue
Orbits
Paranasal Sinuses
Pelvis
Sella/Pituitary
Sternum
Ne
RV
es
X-Ray Brachial Plexus
Lumbosac. Plexus
Sciatic Nerve
cTWO iV
contrastWith iV contrast
Brachial Plexus
Lumbosac. Plexus
Sciatic Nerve
MRisingle
PositionWO iV
contrastWith iV
contrastW/WO iV contrast
Brachial Plexus
Lumbosac. Plexus
Sciatic Nerve
Sacrum
sPiN
e
X-Ray Cervical
Thoracic
Lumbar
Sacrum
MRi* Whiplash Protocol
Multi Position
single Position
WO iV contrast
With iV contrast
W/WO iV contrast
Cervical
Thoracic
Lumbar
Sacrum
*Craniocervical junction
Referring Physician _____________________________________________Physician Signature __________________________________________________
Phone ________________________________ Fax __________________________________ Email __________________________________Date ___________Facility Address _______________________________________________________________________________________________________________________ Email/Fax Report to ___________________________________________________________________________________________________________________
RequiRed FieLds:
cTWO iV
contrastWith iV contrast
Cervical
Thoracic
Lumbar
Sacrum
EXPERTMRITechnology | Science | Evidence
TEL: (877) 674-8888 | FAX: (877) 370-5458 www.expertmri.com | [email protected]
REFERRALs [email protected]
MEdicAL REcoRds [email protected]
signEd LiEns [email protected]
BiLLing & sETTLE REquEsTs [email protected]
Attorney signed liens are required prior
to generating the bill. Always use secured
emails when sending patient information.
cONTAcTs
MOdALiTy key - sTAnd up MRi
- MRi
- cT
- X-RAy
Los Angeles
san diego
Bakersfield
san Bernardino
8
10
155
OVeRVieW
ARE you on ouR pHysiciAns poRTAL?
Print/download diagnostic reports –
View images –
Copy images on a CD –
Need access? Visit http://expertmri.com/request-portal-access/
PORTAL
AddiTiONAL RequiRed dOcuMeNTs
PiWorkers
compMed-Legal PPO
cash Pay
MRi Request Form signed by doctor
demographic sheet including:
claim Number
Adjudication Number
date of injury (dOi)
Patient date of Birth
Patient Phone Number
insurance
diagnosis
employer
Attorney information
Attorney Letter Requesting Med-Legal Report
PTP Letter Requesting Med-Legal diagnostic study
insurance status Letter
copy of insurance card (Front and Back)
LOcATiONs r Bakersfield
r Bellflower
r Beverly Hills
r Colton
r Culver City
r Downtown LA
r Encino
r Fullerton
r Glendale
r Lancaster
r Mission Viejo
r Riverside
r San Bernardino
r San Diego
r Sherman Oaks
r Sun Valley
r Torrance
r Tustin
r Winnetka
Los Angeles
110
405
210
605
5
5
15
15
215
Orange
Riverside
Sherman OaksBeverly Hills
Los AngelesCulver City
Torrance
BellflowerFullerton
TustinMission Viejo
Riverside
San Bernardino
Winnetka
Sun Valley
Lancaster
san Bernardino
V.34
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