Big Sky Imaging - Xray Order Form

Provider Information

Provider's Office *

Clinician Name *

Clinician NPI

Clinician Email

Fax *

Facility Phone

Facility Address *

Facility City *

Facility Zip *

Patient Information

First Name

Last Name *

Gender *

Female

Male

Date of birth *

Street Address

City

State

Postal code

Phone *

Email

Xray Exam Information

CHEST AND ABDOMEN

HEAD AND NECK

LOWER EXTREMITIES

SPINE

UPPER EXTREMITIES

Reason for Exam(ICD10 code or Description of Diagnosis) *

Date of appointment

Additional Note

Insurance Information

Primary Insurance Name *

Primary Policy ID

Secondary Insurance Name

Secondary Policy ID

Submitter Information

Submitter's Name *

Submitter's Phone Number *

Submitter's Email Address

Submitter's Fax Number

Attach the patient's facesheet/clinician order

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.