⬅ Back to Clinician Resources

The forms listed below are in PDF format and require Adobe Reader, which you can download here.

Providence Imaging Center provides several forms that you can download and print.  Some are targeted to clinicians or patients, while others are useful to both.  Simply click on the links to download a PDF of the appropriate form.

 

 

PIC Order Form

This is our current requisition form last revised 12/16, the familiar two pager with the Providence Imaging Center “people” in the upper left hand corner. It lists studies available at our locations in Anchorage and Eagle River, and includes a larger section to detail ICD-10 codes and specificity requirements.


CT Lung Cancer Screening with LDCT

The CT Lung Cancer screening form is new as of April 2015, and should be used for patients referred specifically for lung cancer screening with low dose CT.


PET Order Form

A PET-CT requires that we get some special information in order to get the most accurate results possible. Patients also follow a special diet.


PET-CT Bone Order Form

Use this form to order an 18F-Fluoride PET-CT bone imaging scan, much more sensitive than traditional nuclear medicine bone scans (99mTc).


Special Breast Procedures Order Form

This form is ideal for requesting an MRI of the breast, and includes all breast imaging offered at Providence Imaging Center in Anchorage.


 

CT Prep Sheet

Use this form to check off the appropriate patient prep instructions for drinking the oral CT contrast used in abdomen and abdomen/pelvis CT scans.


Barium Enema Prep Package Instructions

This two-day prep utilizes a prep kit that is available at your clinician’s office or at the front desk of PIC. It ensures that your colon is clean and empty for a succesful examination.


Barium Enema with Air

This two page PDF explains what to expect when you’re having a Barium Enema with air, the most common Barium Enema test.


Barium Enema

This two page PDF explains what to expect when you’re having a Barium Enema without air.


Upper GI Exam

This two page PDF explains what to expect when you’re having an Upper GI Exam.


Small Bowel Series

This two page PDF explains what to expect when you’re having a small bowel series exam.


PET-CT Prep Sheet for Whole Body Imaging

This 6-hour prep ensures that we obtain the best pictures possible.


PET-CT Prep Sheet for Brain Imaging

This prep ensures that we obtain the best pictures possible for patients who have a PET-CT of the brain. Instructions are the same as the prep for Whole-Body Imaging.


PET-CT Bone Instructions

This instructions sheet explains what is needed before you get a PET-CT bone scan; no special diet is required, however.


Breast Cyst Aspiration

This two page PDF that you can download and print includes helpful information on what to expect during the procedure.


Thyroid Biopsy Instructions

This two page PDF that you can download and print includes helpful information on what to expect during an ultrasound-guided thyroid biopsy.


Stereo-Guided and 3D Breast Biopsy Instructions

This two page PDF that you can download and print includes helpful information on what to expect during the stereo guided or 3D procedure.


Ultrasound-Guided Breast Biopsy Instructions

This two page PDF that you can download and print includes helpful information on what to expect during the ultrasound guided procedure.


Ductogram Instructions

This PDF file that you can download and print includes helpful information on what to expect during a ductogram procedure.


Bone Densitometry (DXA) Brochure

Learn about our Hologic Discovery DXA scanner and why bone density testing is important.


Mammography Brochure

Learn about digital mammography and what to expect during a mammogram at PIC.


MRI Brochure

A handy reference that explains what to expect during an MRI exam.


MRI Screening Form

All patients fill out this two sided form to help ensure a safe exam.


Map of Anchorage Clinic

This full-page map is a PDF file that you can download and print, and shows where PIC reserved parking is located in Anchorage.


Direction-Appointment-Card

This two-sided card provides patients a map with travel/parking directions, and has a space to write appointment information.


Clinic Information Card for Providers

This reference provides clinicians and staff with general information about Providence Imaging Center in Anchorage and Eagle River, including our services, scheduling, hours of operation, and contact information.


CT Contrast Guide

This reference sheet is designed for clinicians to help them determine when contrast is necessary for CT exams at PIC.


Breast Imaging Order Tip Sheet for Providers

This handy two-sided reference card for clinicians provides information on correctly scheduling mammography and other breast imaging at our Anchorage location.


PET Reimbursement Guide

This handy two-sided reference guide provides helpful information on which PET exams are covered by Medicare as of 2010.


PET Reimbursement Guide Alzheimers

A guide that explains Medicare coverage criteria for FDG-PET for Alzheimer’s Disease.

Guide for ordering CT exams

Use this guide to know how to schedule a CT exam that includes the area you need covered matched with the reason for the test.


Guide for ordering MRI exams

Use this guide to know how to schedule a MRI exam that includes the area you need covered matched with the reason for the test.


Guide for ordering Ultrasound exams

Use this guide to know how to schedule an Ultrasound exam that includes the area you need covered matched with the reason for the test.

Mammography Release

Use this form to request a medical facility to send PIC mammography films/report(s).


Patient Release

Use this form to have PIC release films/images/report(s) to patients.


PIC Release to Medical Facility

Use this form to have PIC release films/images/report(s) to another medical facility or clinician.


Outside Films Release

Use this form to request a medical facility to send PIC other types of films/images/reports.

 

Financial Assistance

Charity Care Financial Assistance Form

Providence Imaging Center participates in the Charity Care program at Providence Alaska Medical Center. A form is available for patients who would like to see if they qualify for this financial assistance.

Registration Form

To download and print a registration form that you can fill out, click here.