Cardiovascular MRI Procedure Request

Thank you for your interest in UAB Medicine.

For your convenience, we offer two easy methods to refer your patient. Click here to download a printable form, which may be completed and faxed back to us, or simply complete and submit the electronic form below and we will contact your office.

Patient Name

First Last

MRN

DOB

MM slash DD slash YYYY

Sex

Age

Height

Weight

If patient has cardiac pacemaker, defibrillator, ICD, aneurysm clips, or metallic foreign body please notify CVMRI technologist at 205.934.9906. Failure to identify the above can be potentially life threatening to the patient.
If patient weighs more than 250 lbs, please call a CVMRI technologist prior to scheduling study.

Diagnosis

Reason Study is Requested: (Please be very specific. Must include enough clinical information to justify use of Cardiac Magnetic Resonance Imaging. Include any pertinent previous diagnostic testing results.)

Cardiac MRI Procedures Requested:

Ventricular Function

Valve Assessment

Rule-Out Mass

Congenital

Pericardial Disease

Renal Arteries

Thoracic Aorta

Abdominal Aorta

Iliofemorals

Other

Lab

STAT Creatinine/I-STAT

Insurance Information

Primary Carrier:

Policy Holder:

First Last

Policy Number:

Group Number:

Pre-certification Required:

Yes

Secondary Carrier:

Policy Holder:

First Last

Policy Number:

Group Number:

Authorization Number:

Note: Many insurance companies require pre-certification for Cardiac MRI procedures. Please call the number on the back of the patient’s insurance card and obtain an authorization number before scheduling MRI.

Ordered by:

First Last

Date Scheduled:

MM slash DD slash YYYY

Time Scheduled:

Hours

Minutes

Attending MD:

First Last

Extension:

CVMRI Technologist:

First Last

Referring MD:

First Last

Boshell Diabetes Building • 1808 7th Avenue South, Suite 101 • Birmingham, AL 35294 • 205.934.9906 Phone • 205.975.1952 Fax