Search

PAtient referral form

Premier Mountain Imaging Center
Referral Process

At Premier Mountain Imaging Center, we offer state-of-the-art imaging services designed to accommodate the needs of our patients and our referring providers. Our referral process is streamlined to ensure efficient and effective communication between our office, referring physicians, and patients:

  • Insurance and authorization will be verified. 
  • The patient will be contacted to schedule.
  • The physician will be notified of the appointment via fax.
Download

Referral Form Details

Contact Information

  • To schedule an appointment, please call us at 928-216-5250.
  • Our fax number is 928-216-5254, and we are located at 5448 South Highway 260 Suite # 110, Lakeside, AZ 85929.

Patient Information

  • Please provide the patient’s name, date of birth, contact phone number, and email.
  • Additionally, please provide a copy of the patients insurance cards.

Clinical Information

Include the patient’s diagnosis and a brief clinical history to assist in the imaging process.

Imaging Services Requested

  • We offer a range of imaging services X-Ray, CT, MRI, Ultrasound, Dexa, Mammography.
  • Additional services include CTA (Computerated Tomography Angiography, MRA (Magnetic Resonance Angiography), Dynamic Digital Radiography, Tomography.

Referring Provider Details

Please provide the signature of the referring provider, as well as the provider’s name in print.

Submission Instructions

Fax the completed referral form to 928-216-5254 or email it to scheduling@pmicaz.com.

Founded in 2023, Premier Mountain Imaging Centers’ stands as a leader in patient-centered care.  We combine the latest in technological advancements with a direct focus on image quality.  We offer full-service insurance assistance to our patients and healthcare providers as well.

At Premier Mountain Imaging Center, we believe in empowering patients and healthcare providers with clear, accurate, and timely diagnostic information. This commitment to excellence is reflected in every aspect of our operations, making us a trusted partner in the White Mountain’s healthcare community.