Medical Imaging Northwest | Making Referrals

Do's & Don'ts

The Radiology Order Form is a standardized document that must be completed correctly to ensure the proper procedure is accomplished in a timely manner.

The most important part of making a patient referral for an imaging procedure is to provide a comprehensive list of patient signs and symptoms that are the fundamental reason for the examination request. We cannot do procedures based on a Rule/Out diagnosis. We need an actual record of the symptoms the patient is experiencing to demonstrate medical necessity for the exam as well as to provide our interpreting radiologist with the information necessary to determine an accurate diagnosis.

For example, on the Radiology Order Form section 'Written Diagnosis/Reason for Exam Required,' one should write, 'patient is complaining of dizziness, balance problems, and tingling bilaterally in lower extremities,' rather than 'R/O MS'.

Additionally, for patients with complex medical/surgical problems, faxed copies of recent office notes, operative reports, and/or hospital admission/discharge summaries may be particularly helpful in allowing our staff and physicians to tailor the examination to your patient's needs.

On the referral form it is important to indicate:

  • The healthcare provider’s name 
  • Insurance authorization number
  • Social Security number
  • Birth date
  • Phone numbers including a cell number

Plus, it's important that each written order has the ordering provider's original signature.

When completing the Radiology Order Form please don't do the following:

  • Don't omit any patient symptoms or reasons for the exam.
  • Don't use 'R/O' or 'Possible' or 'Probable' reasons for the exam.
  • Don't use blanket codes to order exams, i.e. refer to all DEXA exams for reason of 'osteoporosis' or all mammograms for reason of 'fibrocystic breast disease'.

Each imaging procedure must be based on an individual's medical rationale.

The completed Radiology Order Form may be faxed to the Diagnostic Imaging Northwest Scheduling Department at 253-446-3973 and/or called to 253-841-4353 –Scheduling Department. If you need to order referral slips you can call 253-686-8973 (Marketing Representative) and leave your name, direct telephone line and the type of referral slips that you need and how many. You can email us at and leave a message. You can also copy Downloadable Forms. Maps are also available.

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