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The form facilitates the efficient collection of essential patient and provider information, including contact details, demographic data, and official identifiers such as NPI numbers. It includes dedicated sections for specifying requested radiological services, clinical indications, and relevant ICD-10 diagnosis codes. This structured template streamlines the requisition process, ensuring clear communication between ordering physicians and radiology facilities while supporting accurate scheduling and record-keeping procedures through both phone and online channels.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/radiologyassist-generic-imaging-order-form/307767/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/radiologyassist-generic-imaging-order-form/307767.png","ImageObject",442,249,{"name":88,"@type":89},"Marry","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How can healthcare providers schedule an imaging service for a patient?","Question",{"text":108,"@type":109},"Providers can schedule services by calling 855-346-5152 or by visiting RadiologyAssist.com.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required for the patient section?",{"text":113,"@type":109},"The form requires the patient's name, date of birth, phone number, email address, and full residential address including city, state, and zip code.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical information must the physician provide?",{"text":117,"@type":109},"Physicians must provide the specific services requested, any special instructions, as well as the relevant diagnosis or clinical indications along with corresponding ICD-10 codes.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307767,1790472332,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},5909892079670,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Schedule By Phone  \n855-346-5152  \nSchedule Online  \n[RadiologyAssist.com](RadiologyAssist.com)  \n855-345-5222  \n\n| Patient Information |  |  |  |\n| --- | --- | --- | --- |\n| Patient Name |  | DOB |  |\n| Phone | Email |  |  |\n| Address | City | State | Zip |\n| Provider Information |  |  |  |\n| Provider Name |  | NPI |  |\n| Office Name |  |  |  |\n| Office Address | City | State | Zip |\n| Office Phone | Fax |  |  |\n\nGENERIC IMAGING ORDER FORM  \n\n| Services Requested |\n| --- |\n|  |\n\nSpecial Instructions:  \n\n| Diagnosis/Indications: | ICD-10 Codes: |\n| --- | --- |\n\nPhysician Signature :   Date :","cbCaidPKk8oZ6Ldq","https://ap.wps.com/l/cbCaidPKk8oZ6Ldq","pdf",516161,"English","# Patient Information\n# Provider Information\n# Services Requested\n## Special Instructions\n## Diagnosis and Indications","[{\"question\":\"How can healthcare providers schedule an imaging service for a patient?\",\"answer\":\"Providers can schedule services by calling 855-346-5152 or by visiting RadiologyAssist.com.\"},{\"question\":\"What information is required for the patient section?\",\"answer\":\"The form requires the patient's name, date of birth, phone number, email address, and full residential address including city, state, and zip code.\"},{\"question\":\"What clinical information must the physician provide?\",\"answer\":\"Physicians must provide the specific services requested, any special instructions, as well as the relevant diagnosis or clinical indications along with corresponding ICD-10 codes.\"}]","RadiologyAssist - Generic Imaging Order Form | PDF",1789854682]