Physicians Menu

Educational Links

Sign up for our Newsletter


Name:

Email:

News and Events

Affiliations and Partners

logo_siemens

logo_hitachi

PETLinq

getaPETscan

IBA


Connect With Us

Follow Us On Twitter
Follow Us On Twitter

Become A Fan On FaceBook
Become A Fan On FaceBook

Watch Our YouTube Channel
Watch Our YouTube Channel
Click on the slide!

The Women's Center

Click on the slide!

Patient Procedures

Has you physician ordered a diagnostic imaging procedure for you?

MORE
Click on the slide!

PET/CT

Executive Scans

This tool allows physicians to pinpoint the location of cancer within the body.

Click on the slide!

International Patients

International Patients

Elite Imaging caters to international patients from all over the Bahamas.

Click on the slide!

MRI

MRI Services

Elite Imaging offers state-of-the-art MRI services, performed by highly trained MRI technologists.

Click on the slide!

Services

Our Services

From MRIs and MRAs to PET/CTs and Bone Scans, make Elite Imaging your choice, everytime.

Frontpage Slideshow (version 2.0.0) - Copyright © 2006-2008 by JoomlaWorks

Referral/Requisition Form

To assist physicians and their staff in referring patients to Elite Imaging, we have made available a copy of the Patient Requisition form for your use.

For routine studies, your office can call our central schedulers 305.692.2222. The earliest and most convenient appointment will be set up for your patient. We must receive a written request containing the clinical information and diagnosis. This should be faxed to our schedulers at 305.692.2233 and then given to your patient to bring to their appointment. A printable copy of our request form can be downloaded here.

MRI/CT/CTA


MRA
If you selected MRA above, please enter the details.
CTA
If you selected CTA above, please enter the details.
Other
If you selected other above, please enter the details here.

PET/CT


Tumor Type
If you selected Diagnosis/Tumor Type, please enter the details here.

PATIENT INFORMATION
Patient Full Name
Enter your last name, first name, middle initial in this field.
Social Security Number
Enter your social security number into this field.
Date Of Birth
Specify your date of birth using this field. Use the date selector.
Home Phone
Please enter your telephone using the format of (123)456-7890.
Other Phone
Please enter your telephone using the format of (123)456-7890.
Patient Address
Please enter your personal address into this field.

INSURANCE INFORMATION
Insurance Company Name
Enter the name of the insurance company name here.
Insurance Phone
Please enter the insurance company's telephone using the format of (123)456-7890.
Group No.
Enter the group number of your insurance into this field.
Policy No.
Enter the primary policy number in this field.
ID No.
Enter the primary policy ID number in this field.
Claim No.
Enter the claim number your insurance company provided you into this field.
Authorization Number
Please enter the authorization number into this field.
Date Of Accident
If your visit was due to an injury, please specify the date of this injury here using the format 01/01/2009.
Attorney Name
Use this field to specify the attorney's name.
Attorney Phone
Please enter your telephone using the format of (123)456-7890.

PHYSICIAN INFORMATION
Referring Physician
Please enter the physician's name into this field.
Physician Telephone
Enter the physician's office telephone here.
Office Contact
Please enter the person's name that should be contacted in the physician's office if questions arise.
Extension
Please enter the extension number for the contact.
Comparison Films
Enter the comparison films here.
Fax Report To
Enter the telephone number where the report should be faxed to using the format of (123)456-7890.
Diagnosis
Please specify the diagnosis using this field.
Special Instructions
Please enter any special instructions from the referring physician.
Physician's Access ID
Please enter your physician's access ID into this field. You should have received this from Elite Imaging.
Submission/Signature Date
You MUST select a date as your submission/signature date before this form can be submitted.
  Back To The Top

 

  
ACR Accredidation

Our Locations

View Our LocationsVisit one of our locations. Get your maps and directions here.

Meet Our Staff

Meet Our StaffView contact information for our staff here.

Read Our Blog

Read Our BlogDon't leave our website until you read our blog.

Customer Support

1-866-4ELITE2
1-305-692-2222

Click Here...