Radiology Request Form
For faster service please use the Radiology Information System (RIS) to order your study.
This request form is for services performed at the UHB campus only, and can be used by Physicians, Doctors of Osteopathic Medicine, Physician Assistants, Nurse Practitioners, and other clinicians.
The proper processing of requests depends upon the completion of pertinent medical and referrer information such provider NPI, pre-certification information if applicable, and patient history.
General Radiology Request Form:
Open, fill out, print and save this PDF version of the Radiology Request Form. A completed copy must be faxed to 718-270-4172 for processing.
Interventional Radiology Request Form:
Critical Findings Report Form:
