Referral Services: Forms
Due to HIPPA, we now require a HIPAA business agreement between your office and Logan University. If we are billing your office, we need a signed business agreement and an Imaging Interpretation Form filled out and signed by the referring doctor.
If we are billing the patient and/or filing the patient’s insurance, we need the flowing:
Signed business agreement
- Imaging Interpretation Form filled out & signed by referring doctor
- Patient’s signature on Informed Consent for Imaging Interpretation form
- Enclose a copy of their insurance card front and back.
If you have any questions, feel free to contact the Department of Radiology at (800) 782-3344, ext. 1830 or email firstname.lastname@example.org. If you are a sending films, please send to:
ATTN: Dr. Norman Kettner, Radiology Department
1851 Schoettler Road
PO Box 1065
Chesterfield, MO 63006-1065