Please use this form to order imaging / Radiology studies from UTMB for your St. Vincent’s patients. Please exercise prudence, as we have limited funds, and order only those tests that will result in a change in the medical management of your patient. If the test undergoes committee review, you will be asked to place the orders within one week. Please monitor your Epic InBasket and email for updates.

We appreciate your assistance. If you have any questions, please contact Julian Quiceno or Dr. Farr.

FAQ

Does your patient have a legal status in the US?

If your patient has a legal status consider recommending applying for Casebook or indigent care funding as this will allow them to qualify for specialty care if necessary.

what is your UTMB username?

Please double check this field. If your username is wrong, the request will not go through.

Who is the faculty member prescribing this test?

If you are a resident, please add your name as well as the name of the faculty member you checked out to.

Faculty UTMB Username(Required)

Faculty Phone Number

We will only use this number to call and notify faculty if test is approved or denied. This is optional.

What is your patient's MRN?

What are your patient's initials?

Does your patient have insurance?

Yes

Since your patient has insurance, please place a referral via Epic or refer the patient to Coastal Health and Wellness as they are able to use their insurance to access imaging services.

They will NOT qualify for discounted or grant funded tests. If you believe that this is a mistake, you can still submit the form for committee review by providing the information below:

Imaging Test Information

What type of test does your patient need?

What kind of test?

This field is hidden when viewing the form

Cost of Test

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Approval Status of Test

Affordability

Cost of Study

The cost of a is Dollars

Would your patient be able to donate $ – dollars towards the cost of their ?

Since the patient cannot donate to cover the entire costs, can they donate to cover some of the costs? if so, how much can they donate?

Leave empty if patient is unable to donate any funds

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Donating Section

When you submit this form we will automatically send your patient a text message with the cost of their procedure and the donation page link.

Patient Phone Number

Language

I hereby consent to receive SMS messages for the purpose of receiving updates about my patient assistance application. I understand that these messages may include information about the status of my application, medication refill reminders, and other relevant updates. I acknowledge that standard message and data rates may apply, and I am responsible for any associated costs. I may opt-out of receiving SMS messages at any time by following the provided instructions. By providing my consent, I confirm that I have read and understood the terms and conditions of receiving SMS updates. My consent is voluntary and can be revoked at any time.

Reason for Test

What is the reason for the test?(Required)

How will this change medical management?(Required)

This Test is Pre-Approved!

This test is pre-approved, please click below for further instructions.

Committee Review Needed

Please provide any details about what was discussed with the patient and plan for follow-up that would be hepful for the committee to know.

This test requires committee approval. This review process ensures that grant funds are used judiciously and can continue to support the maximum number of patients. Please consider other sources of funding for your patient, such as casebook or indigent care, especially if your patient requires additional care in the event of a positive test result and can wait for this paperwork to be completed. The prescriber and attending physician will receive an email within one week, providing information about the approval or denial of the request. Please understand that this committee review is vital to ensure that imaging studies are limited to cases where the results can truly impact the treatment plan. Your cooperation in this process is greatly appreciated, as it helps us allocate resources effectively and provide the best care to our patients.

Imaging Orders

Imaging Test Information

Affordability

The cost of a is Dollars

Donating Section

Reason for Test

This Test is Pre-Approved!

Committee Review Needed

Useful Links