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:

The cost of a is Dollars

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.

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.

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

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.