What is the Radiology Assist Program ?

Radiology Assist is a free resource available to the under-insured community giving individuals access to affordable diagnostic imaging.

The program offers the following radiology imaging at a low discounted rate :
1. MRI
2. CT Scan
3. PET Scan
4. Ultrasound
5. Xray
6. Mammogram

Our low affordable rates are available at any participating imaging centers when appointments are scheduled through the program. There is no fee to use the program.

The program is intended to assist the under-insured control the cost of imaging in their time of need.

Nationwide Access To Affordable Imaging

2100 Valley View Ln #490, Farmers Branch TX 75234 | Phone : 1-855-346-5152 | Fax : 1-855-345-5222

Refer a patient

For providers only.
Please use this form to submit an eReferral. RadiologyAssist will reach out to the patient for scheduling.
Ordering Provider
Provider Name*
Data presented from NPI database. You can update the address on the next page.
Imaging Study
Imaging Study Being Ordered*
Please write name of study
- I am unable to find the imaging study needed
Diagnosis
Diagnosis
For lateral studies, which side?*
- Left
- Right
- Both (Bilateral)
- N/A
Additional Instructions
Additional instructions to include on order
These notes for the imaging center will be included at the bottom of the order.

Patient Information
Patient Name*
First Last
Date of birth*
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Address
Street Address Address Line 2 City State Zip Code
Phone*
Please ensure it is accurate and you are reachable at this number.
Email
Note to providers
Patients must be informed to call RadiologyAssist at 855-346-5152 to schedule their appointment
Provider Information
NPI
Please verify that provider data is accurate
Provider Name
First Last
Provider Address
Street Address Address Line 2 City State Zip Code
Provider Phone
Provider Fax*
Sign Order
Your Name*
Please certify*
- 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
*
- Patient is aware about this referral and has been informed to call RadiologyAssist at 855-346-5152
Comments
This field is for validation purposes and should be left unchanged.

Already have an order?

Fax Referral

Fax a completed referral to 855-345-5222.

Download Order Form

Upload Referral

Submit a referral using the secure upload form.

Upload Referrals

All-inclusive Rates Nationwide Rates starting from :
$265	MRI w/o contrast
$130	CT Scan w/o contrast
$140	Mammogram Screening or diagnostic
$115	Ultrasound Most Body Part
$33	X Ray 2 views

What is the Radiology Assist Program ?

Refer a patient

Ordering Provider

Imaging Study

Diagnosis

Additional Instructions

Patient Information

Note to providers

Provider Information

Sign Order

Already have an order?

Fax Referral

Upload Referral