Please complete and send for a free estimate.
Please complete and send for a free estimate.
Please complete for a free estimate.
There was a problem with your submission.
Errors have been
highlighted
below.
Your Information
Do you have an order?
*
Do you have an order?
No
Yes
This field is required. Please enter a value.
Are you already scheduled with us?
*
Are you already scheduled with us?
No
Yes
This field is required. Please enter a value.
A signed physician's order is required.
Please contact your physician and try again with order in hand.
Please contact our facility for any questions regarding an existing appointment by calling us at 703.242.2106
Your name
Your name
*
First
Last
This field is required. Please enter a value.
Insurance Information
Will you be filing insurance?
*
Will you be filing insurance?
No
Yes
This field is required. Please enter a value.
Your date of birth
Your date of birth
/
MM
/
DD
YYYY
Please enter a valid date.
Insurance company
Insurance ID number
Phone number for eligibility and benefits
Phone number for eligibility and benefits
-
###
-
###
####
Please enter a valid phone number.
Exam Details
Modality / Type of exam
*
MRI
CT
Ultrasound
Arthrogram
X-ray
This field is required. Please enter a value.
Body part?
*
This field is required. Please enter a value.
Contrast required?
*
Without
With
With and Without
Radiologist discretion
Not applicable
Not sure
This field is required. Please enter a value.
Please select your preferred location.
UVA Health Outpatient Imaging Centreville
UVA Health Outpatient Imaging Centreville
Charleston
Columbia
Florence
Myrtle Beach
Spartanburg
The Best Way To Reach You
Preferred method of contact
*
Preferred method of contact
Email
Phone
This field is required. Please enter a value.
Your email address
*
Confirm email address
*
Please enter a valid/confirmed email address.
This field is required. Please enter a value.
Primary phone number
Primary phone number
*
-
###
-
###
####
Please enter a valid phone number.
This field is required. Please enter a value.
Alternate phone number
Alternate phone number
-
###
-
###
####
Please enter a valid phone number
Additional Information
How did you hear about us?
*
Referring Physician
Online search
Radio
My insurance company
Family member / friend
Community event
I have been a patient before
Other
This field is required. Please enter a value.
If other, please let us know how
Any additional comments that you would like to share
PLEASE NOTE:
If you elected to be contacted by email, please note that all correspondence from UVA Health Outpatient Imaging Centreville will be encrypted, and you will need to log into a secure portal to retrieve your messages.
*
If you elected to be contacted by email, please note that all correspondence from UVA Health Outpatient Imaging Centreville will be encrypted, and you will need to log into a secure portal to retrieve your messages.
I agree
This field is required. Please enter a value.
UVA Health Outpatient Imaging Centreville 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 UVA Health Outpatient Imaging Centreville to acquire certain data required to calculate your estimated financial responsibilities related to the respective imaging exam you have selected on this request form.
*
UVA Health Outpatient Imaging Centreville 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 UVA Health Outpatient Imaging Centreville to acquire certain data required to calculate your estimated financial responsibilities related to the respective imaging exam you have selected on this request form.
I agree
This field is required. Please enter a value.
Spam Protection. Please answer this simple question.
If yesterday was Monday what day is today?
This field is required. Please enter a value.