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MRI Procedure Request Form

Please note that this MRI Procedure Request form is for letter of protection only. If the MRI is to be billed to the patient’s primary insurance then please call us for the standard Greater Waterbury Imaging Center scan order form.
  • Please enter the last four of the patient's social security number and we will call to get the full number.
  • Please enter valid email so that we can send you a copy of the form.
  • Please enter the Referring Physician Name. In order to approve the request, we will need to have the Referring Physician sign the form and fax to our office. We will contact you shortly to confirm the request.
  • This field is for validation purposes and should be left unchanged.
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