Facility Order - Stat Portable X-Ray

Facility Order Request

Patient Information:

Male Female

Attach Face Sheet (optional)

Medicare Number:

Medicaid Number:

Other Insurance Provider:

Policy Number:

Order another exam?

Upload Script:

- or -

I will fax script or requisition

“NOTE: Exam will not be finalized until fax is received”

(optional, for confirmation only)

Completed

Refused / NA

Nurse Signature:

____________________________

Tech Signature:

____________________________