Physicians

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External Image Upload Request

All outside images for patient care require the following information to be submitted with the images.

Date *

Patient Name *

DOB *

Name of referring provider requesting imaging be sent to UMMC *

Name of provider at UMMC requesting imaging (must have a UMMC provider aware of incoming imaging).

MD pager or practicing clinic phone number *

Person completing this form *

Contact number or pager *

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