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ADIN Healthcare Imaging Network Scheduling Form

By completing the following form, you may securely request a diagnostic imaging exam. If you prefer, you may also schedule a procedure with ADIN Healthcare by calling toll-free: 866 MRI or CT (866.674.6728), sending a fax to (800) 818-3112 or by sending the appropriate information via email to schedule@adinhealthcare.com .  

* Fields with an asterisk are required.

Submitted By
You are the (if "Other" enter name and phone)
Name
Phone
Preferred method of communiction Phone Fax Email
Case Manager Information
Company Name *
First Name *
Last Name *
Address
City
State
Zip
Phone *
Extension
Fax
Email
Patient Information
First Name *
MI
Last Name *
Address *
City *
State *
Zip *
Home Ph *
Work Ph
Extension
Cell Phone / Ohter
SSN *
DOB * (mm/dd/yyyy)
Date of injury *
Language
Employer Information
Employer Name
Employer Ph
Address
City
State
Zip
Referring Physician
First Name *
MI
Last Name *
Specialty
Address
City
State
Zip
Phone *
Extension
Fax
Insurer's Information
Company Name *
Claim Number *
Address *
City *
State *
Zip *
Adjuster Information
First Name *
MI
Last Name *
Address
City
State
Zip
Phone *
Extension
Fax
Email
Procedure(s) Requested
Procedure 1 * Body Area 1
Diagnosis 1
Procedure 2 Body Area 2
Diagnosis 2
Procedure 3 Body Area 3
Diagnosis 3
Prescription orders to come from
Additional Comments
Comments

 




 

 

 

 

 
ADIN Healthcare, LLC
256 Seaboard Lane, D 101
Franklin, TN 37067