Diagnostic Imaging Request

Diagnostic Imaging Request

Intake Form for Diagnostic MRI & Imaging Referral
  • ***Please Note***

    This service is for CASH PAY ONLY imaging . We DO NOT obtain prior authorization from insurance. Many imaging centers offer cash discounts, which are often less than insurance rates. If you have a high deductible health plan, the cash pay option is ideal. If you desire to run the imaging study through your insurance, we ask that you personally submit the required documentation directly to both the imaging center and your insurance carrier. We cannot guarantee that your insurance will cover the cost of the diagnostic imaging study. Again, Cirrus Medical Network will not submit your imaging request through your health insurance. Allow at least 1 business day to process the referral. We will attempt to send the order directly to the imaging center of your choice. In addition, you will be sent a copy of the order via the patient portal in the form of a PDF attachment.
  • Please describe what symptoms you are having and why you are requesting this test?
  • Which body part(s) would you like scanned?
  • If you know that you would like a contrast with your imaging test, please indicate so below. Note - Most Spine & Joint MRI's and CT scans do NOT require contrast. If you have a history of kidney disease, you should avoid contrast. You may be asked to provide laboratory evidence of recent kidney function tests (e.g. BUN/Creatinine/GFR) prior to undergoing a contrast-enhanced study.
  • Have you every had a reaction to contrast dye?
  • Please indicate which imaging center you would like us to send your referral to. Example: "PRECISE IMAGING 8641 Wilshire Blvd. Suite 105 Beverly Hills, CA 90211". At a minimum, please include the facility NAME and ZIP CODE.
  • Anything else you would like to add?

 

Please allow 1 business day to process your imaging request. You should receive an email confirmation, once the referral has been sent to the imaging center.

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