tester – Florence MRI & Imaging

Do you have an order from your healthcare provider?

Yes No

First and last name of referring provider

First Name

Last Name

Date of birth

Phone

Is that number a cell phone that can receive texts?

Yes No

Request Date

Request Time

Comments

Correspondence

If you elected to be contacted by email, please note that all correspondence from Florence MRI will be encrypted, and you will need to log into a secure portal to retrieve your messages.

Security and Privacy

Florence MRI takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Florence MRI to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form.