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SEAMLESS REFERRAL FORM
Seamless Referral Form
Referral
Diagnostic Testing
Durable Medical Equipment
Hearing Aids
Home Health
Other
I am:
Physician
Adjuster
Nurse
Patient
Other
Patient
Information
First name
Last name
Phone
Address
DOB
Patient MRN
Patient DOI (mm/dd/yyyy)
Script Date (mm/dd/yyyy)
Insurance
Information
Insurance Company
Claim Number
WCB Number
Employer
Adjuster
Information
Adjuster Name
Adjuster Phone Number
Adjuster Fax Number
Adjuster Email
Referral
Information
Service Required [Test]
Body Part
CPT Code
Clinical HX/Symptoms
Urgent Y/N
Other Services Requested
Referring Facility
Referring Physician
Todays Date
Does JAG need to schedule this patient at an outside facility? (due to claustrophobia, modalities, etc?)
Yes
No
Appointment
Information
Date of Scan (if scheduled)
Facility Performing Scan
Time
Time
:
Hours
Minutes
Final
Steps
Additional Notes/Information
Attach
Supporting Documentation
Upload File
Max 15MB
Upload File
Max 15MB
Email for Confirmation
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Submit
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