Referring Providers – Request an MRI

Prior to referring a patient for an MRI with OIP, please review the MRI Preauth Documentation Guidelines from NIA.

Abdomen and MRCP
Brain
Chest
Lower Extremity
Pelvis
Spine
Upper Extremity

Last Updated on 04/16/2020

To refer a patient for an MRI, please complete the form below or call our MRI Department directly at (717) 909-1234.

Referring Provider Information

Referring Provider Name *

E-mail Address (optional)

Phone Number *

Fax *

Patient Information

First Name *

M.I.

Last Name, with suffix *

Phone Number *

Birth Date *

Reason For Appointment *

Will this patient need an interpreter? *

Comments

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Click "Submit" to process your 'Request an MRI' Form.