{"id":12388,"date":"2025-05-01T12:32:03","date_gmt":"2025-05-01T18:32:03","guid":{"rendered":"https:\/\/radiologyassist.com\/StagingAvada\/?page_id=12388"},"modified":"2025-05-22T13:46:18","modified_gmt":"2025-05-22T19:46:18","slug":"refer","status":"publish","type":"page","link":"https:\/\/radiologyassist.com\/StagingAvada\/refer\/","title":{"rendered":"Refer a Patient"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-min-height:271px;--awb-background-image:url(&quot;https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/uploads\/2025\/04\/BG_Footer.png&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1331.2px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column fusion-flex-align-self-center\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#ffffff;--awb-font-size:30px;\"><h1 class=\"fusion-title-heading title-heading-left\" style=\"font-family:&quot;Open Sans&quot;;font-style:normal;font-weight:700;margin:0;font-size:1em;line-height:20px;\">Refer a Patient <span style=\"font-size: 20px; font-weight: normal;\">(For providers only)<\/span><\/h1><\/div><div class=\"fusion-text fusion-text-1\" style=\"--awb-content-alignment:left;--awb-font-size:18px;--awb-line-height:24px;--awb-text-color:#ffffff;--awb-margin-top:-10px;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\"><p>Please use this form to submit a Quick Referral. RadiologyAssist will reach out to the patient for scheduling.<br \/>\nYou may alternatively sign up for our Provider Portal to refer and track your referrals and download reports.<\/p>\n<\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:30px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1331.2px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_3 2_3 fusion-flex-column gravity-upload-referral-form\" style=\"--awb-bg-size:cover;--awb-width-large:66.666666666667%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.88%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.88%;--awb-width-medium:60%;--awb-order-medium:0;--awb-spacing-right-medium:3.2%;--awb-spacing-left-medium:3.2%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\" style=\"--awb-content-alignment:left;--awb-font-size:18px;--awb-line-height:24px;--awb-text-color:#520a1c;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_47' style='display:none'><div id='gf_47' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_47' id='gform_47'  action='\/StagingAvada\/wp-json\/wp\/v2\/pages\/12388#gf_47'>\n                        <div class='gform_body'><div id='gform_page_47_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_47' class='gform_fields top_label form_sublabel_below description_below'><li id='field_47_115'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Ordering Provider<\/h2><\/li><li id='field_47_133'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><link rel=\"stylesheet\" href=\"https:\/\/code.jquery.com\/ui\/1.12.1\/themes\/base\/jquery-ui.css\">\n<script\n  src=\"https:\/\/code.jquery.com\/ui\/1.12.0\/jquery-ui.min.js\"\n  integrity=\"sha256-eGE6blurk5sHj+rmkfsGYeKyZx3M4bG+ZlFyA7Kns7E=\"\n  crossorigin=\"anonymous\">\n<\/script>\n<link href=\"https:\/\/cdn.jsdelivr.net\/npm\/select2@4.0.13\/dist\/css\/select2.min.css\" rel=\"stylesheet\" \/>\n<script src=\"https:\/\/cdn.jsdelivr.net\/npm\/select2@4.0.13\/dist\/js\/select2.min.js\"><\/script>\n\n<script type='text\/javascript' src=\"https:\/\/radiologyassist.com\/js\/SubmitAReferral_StagingAvada_V2\/SubmitAReferral_StagingAvada_V2.js\"><\/script>\n<\/li><li id='field_47_106'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_47_106' >Provider Name<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_47_106'>Data presented from NPI database. You can update the address on the next page.<\/div><div class='ginput_container ginput_container_text'><input name='input_106' id='input_47_106' type='text' value='' class='large'  aria-describedby=\"gfield_description_47_106\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_47_132'  class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><\/li><li id='field_47_70'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Imaging Study<\/h2><\/li><li id='field_47_94'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_94' >Imaging Study Being Ordered<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_94[]' id='input_47_94' class='medium gfield_select'  ><option value='' ><\/option><\/select><\/div><\/li><li id='field_47_111'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_111' >Please write name of study<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_47_111' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_47_110'  class='gfield hide_label field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_47_110'><li class='gchoice_47_110_1'>\n\t\t\t\t\t\t\t\t<input name='input_110.1' type='checkbox'  value='I am unable to find the imaging study needed'  id='choice_47_110_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_47_110_1' id='label_47_110_1'>I am unable to find the imaging study needed<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_47_108'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Diagnosis<\/h2><\/li><li id='field_47_109'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_109' >Diagnosis<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_109[]' id='input_47_109' class='medium gfield_select'  ><option value='' ><\/option><option value='A001,&quot;A001&quot;' >A001,&quot;A001&quot;<\/option><\/select><\/div><\/li><li id='field_47_98'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >For lateral studies, which side?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_47_98'><li class='gchoice_47_98_0'><input name='input_98' type='radio' value='Left'  id='choice_47_98_0'    \/><label for='choice_47_98_0' id='label_47_98_0'>Left<\/label><\/li><li class='gchoice_47_98_1'><input name='input_98' type='radio' value='Right'  id='choice_47_98_1'    \/><label for='choice_47_98_1' id='label_47_98_1'>Right<\/label><\/li><li class='gchoice_47_98_2'><input name='input_98' type='radio' value='Both (Bilateral)'  id='choice_47_98_2'    \/><label for='choice_47_98_2' id='label_47_98_2'>Both (Bilateral)<\/label><\/li><li class='gchoice_47_98_3'><input name='input_98' type='radio' value='N\/A'  id='choice_47_98_3'    \/><label for='choice_47_98_3' id='label_47_98_3'>N\/A<\/label><\/li><\/ul><\/div><\/li><li id='field_47_113'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Additional Instructions<\/h2><\/li><li id='field_47_114'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_47_114' >Additional instructions to include on order<\/label><div class='gfield_description' id='gfield_description_47_114'>These notes for the imaging center will be included at the bottom of the order.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_47_114' class='textarea medium'  aria-describedby=\"gfield_description_47_114\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_47_124' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_47\").val(\"2\");  jQuery(\"#gform_47\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_47\").val(\"2\");  jQuery(\"#gform_47\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_47_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_47_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_47_4'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Patient Information<\/h2><\/li><li id='field_47_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Patient Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_47_3'>\n                            \n                            <span id='input_47_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_47_3_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_47_3_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_47_3_6_container' class='name_last' >\n                                                    <input type='text' name='input_3.6' id='input_47_3_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_47_3_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_47_7'  class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_7' >Date of birth<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_47_7' type='text' value='' class='datepicker medium mdy datepicker_no_icon'    aria-describedby='input_47_7_date_format' \/>\n                            <span id='input_47_7_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_47_7' class='gform_hidden' value='https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/plugins\/gravityforms-2.4.20\/images\/calendar.png'\/><\/li><li id='field_47_9'  class='gfield gf_right_half gf_list_inline field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_47_9'><li class='gchoice_47_9_0'><input name='input_9' type='radio' value='Male'  id='choice_47_9_0'    \/><label for='choice_47_9_0' id='label_47_9_0'>Male<\/label><\/li><li class='gchoice_47_9_1'><input name='input_9' type='radio' value='Female'  id='choice_47_9_1'    \/><label for='choice_47_9_1' id='label_47_9_1'>Female<\/label><\/li><\/ul><\/div><\/li><li id='field_47_8'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_47_8' >\n                         <span class='ginput_full address_line_1' id='input_47_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_47_8_1' value=''    \/>\n                                        <label for='input_47_8_1' id='input_47_8_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_47_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_47_8_2' value=''   \/>\n                                        <label for='input_47_8_2' id='input_47_8_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_47_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_47_8_3' value=''    \/>\n                                    <label for='input_47_8_3' id='input_47_8_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_47_8_4_container' >\n                                        <select name='input_8.4' id='input_47_8_4'     ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_47_8_4' id='input_47_8_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_47_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_47_8_5' value=''    \/>\n                                    <label for='input_47_8_5' id='input_47_8_5_label' >Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_47_8_6' value='USAB'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_47_6'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_47_6' >Phone<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_47_6'>Please ensure it is accurate and you are reachable at this number.<\/div><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_47_6' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_47_6\" \/><\/div><\/li><li id='field_47_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_5' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_47_5' type='email' value='' class='large'     aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_47_121'  class='gfield Request_Form_Info gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h2>Note to providers<\/h2>\nPatients must be informed to call RadiologyAssist at 855-346-5152 to schedule their appointment<\/li><li id='field_47_130'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Provider Information<\/h2><\/li><li id='field_47_125'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_47_125' >NPI<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_47_125' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_47_131'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' >Please verify that provider data is accurate<\/li><li id='field_47_126'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Provider Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_47_126'>\n                            \n                            <span id='input_47_126_3_container' class='name_first' >\n                                                    <input type='text' name='input_126.3' id='input_47_126_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_47_126_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_47_126_6_container' class='name_last' >\n                                                    <input type='text' name='input_126.6' id='input_47_126_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_47_126_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_47_127'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Provider Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_47_127' >\n                         <span class='ginput_full address_line_1' id='input_47_127_1_container' >\n                                        <input type='text' name='input_127.1' id='input_47_127_1' value=''    \/>\n                                        <label for='input_47_127_1' id='input_47_127_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_47_127_2_container' >\n                                        <input type='text' name='input_127.2' id='input_47_127_2' value=''   \/>\n                                        <label for='input_47_127_2' id='input_47_127_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_47_127_3_container' >\n                                    <input type='text' name='input_127.3' id='input_47_127_3' value=''    \/>\n                                    <label for='input_47_127_3' id='input_47_127_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_47_127_4_container' >\n                                        <select name='input_127.4' id='input_47_127_4'     ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_47_127_4' id='input_47_127_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_47_127_5_container' >\n                                    <input type='text' name='input_127.5' id='input_47_127_5' value=''    \/>\n                                    <label for='input_47_127_5' id='input_47_127_5_label' >Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_127.6' id='input_47_127_6' value='USAB'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_47_128'  class='gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_128' >Provider Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_47_128' type='tel' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_47_129'  class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_47_129' >Provider Fax<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_47_129' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_47_107'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><link href='https:\/\/clinicaltables.nlm.nih.gov\/autocomplete-lhc-versions\/17.0.2\/autocomplete-lhc.min.css' rel=\"stylesheet\">\n<script src='https:\/\/clinicaltables.nlm.nih.gov\/autocomplete-lhc-versions\/17.0.3\/autocomplete-lhc.min.js'><\/script>\n<\/li><li id='field_47_116'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Sign Order<\/h2><\/li><li id='field_47_117'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_47_117' >Your Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_47_117' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_47_34'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Please certify<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_47_34'><li class='gchoice_47_34_1'>\n\t\t\t\t\t\t\t\t<input name='input_34.1' type='checkbox'  value='I certify under penalty of perjury under the laws of the United States of America that I am authorized to sign this electronic imaging order on behalf of the ordering provider'  id='choice_47_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_47_34_1' id='label_47_34_1'>I certify under penalty of perjury under the laws of the United States of America that I am authorized to sign this electronic imaging order on behalf of the ordering provider<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_47_120'  class='gfield hide_label gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_47_120'><li class='gchoice_47_120_1'>\n\t\t\t\t\t\t\t\t<input name='input_120.1' type='checkbox'  value='Patient is aware about this referral and has been informed to call RadiologyAssist at 855-346-5152'  id='choice_47_120_1'   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style=\"--awb-padding-right-medium:14px;--awb-padding-left-medium:16px;--awb-overflow:hidden;--awb-bg-size:cover;--awb-border-radius:30px 30px 30px 30px;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:40%;--awb-order-medium:0;--awb-spacing-right-medium:4.8%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3\" style=\"--awb-content-alignment:center;--awb-font-size:24px;--awb-text-color:#6d0d26;--awb-margin-top:20px;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:700;\"><p>Already have an order?<\/p>\n<\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\" style=\"--awb-overflow:hidden;--awb-bg-color:#fdf5f5;--awb-bg-color-hover:#fdf5f5;--awb-bg-size:cover;--awb-border-radius:30px 30px 30px 30px;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:9.696%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:9.6%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-4\" style=\"--awb-content-alignment:center;--awb-font-size:20px;--awb-text-color:#6d0d26;--awb-margin-top:20px;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:700;\"><p>Fax Referral<\/p>\n<\/div><div class=\"fusion-text fusion-text-5\" style=\"--awb-content-alignment:center;--awb-font-size:18px;--awb-line-height:23px;--awb-text-color:#6d0d26;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\"><p>Fax a completed referral to<br \/>\n<strong>855-345-5222.<\/strong><\/p>\n<\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat button-large button-custom fusion-button-default button-1 fusion-button-default-span fusion-button-default-type procedure-buttons-ult\" style=\"--button_accent_color:#ffffff;--button_accent_hover_color:#ffffff;--button_border_hover_color:#ffffff;--button_gradient_top_color:#911536;--button_gradient_bottom_color:#911536;--button_gradient_top_color_hover:#6d0d26;--button_gradient_bottom_color_hover:#6d0d26;--button_typography-font-family:&quot;Open Sans&quot;;--button_typography-font-style:normal;--button_typography-font-weight:700;--button_margin-bottom:20px;\" target=\"_self\" href=\"https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/uploads\/2025\/05\/RadiologyAssist_PCP_Requisition_Generic.pdf\"><span class=\"fusion-button-text\">Download Order Form<\/span><\/a><\/div><\/div><\/div><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-1 fusion_builder_column_inner_1_1 1_1 fusion-flex-column\" style=\"--awb-overflow:hidden;--awb-bg-color:#fdf5f5;--awb-bg-color-hover:#fdf5f5;--awb-bg-size:cover;--awb-border-radius:30px 30px 30px 30px;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:9.696%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:9.6%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-6\" style=\"--awb-content-alignment:center;--awb-font-size:20px;--awb-text-color:#6d0d26;--awb-margin-top:20px;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:700;\"><p>Upload Referral<\/p>\n<\/div><div class=\"fusion-text fusion-text-7\" style=\"--awb-content-alignment:center;--awb-font-size:18px;--awb-line-height:23px;--awb-text-color:#6d0d26;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\"><p>Submit a referral using the secure upload form.<\/p>\n<\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat button-large button-custom fusion-button-default button-2 fusion-button-default-span fusion-button-default-type procedure-buttons-ult\" style=\"--button_accent_color:#ffffff;--button_accent_hover_color:#ffffff;--button_border_hover_color:#ffffff;--button_gradient_top_color:#911536;--button_gradient_bottom_color:#911536;--button_gradient_top_color_hover:#6d0d26;--button_gradient_bottom_color_hover:#6d0d26;--button_typography-font-family:&quot;Open Sans&quot;;--button_typography-font-style:normal;--button_typography-font-weight:700;--button_margin-bottom:20px;\" target=\"_self\" href=\"https:\/\/radiologyassist.com\/StagingAvada\/upload-referral\/\"><span class=\"fusion-button-text\">Upload Referrals<\/span><\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":15,"featured_media":0,"parent":0,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":""},"class_list":["post-12388","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/pages\/12388","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/comments?post=12388"}],"version-history":[{"count":0,"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/pages\/12388\/revisions"}],"wp:attachment":[{"href":"https:\/\/radiologyassist.com\/StagingAvada\/wp-json\/wp\/v2\/media?parent=12388"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}