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Forms

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 the left to download a PDF of the appropriate form.

Release Forms

Mammography Release

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

Patient Release

PIC Release to Medical Facility

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

Preps/Instructions

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 12-hour prep ensures that we obtain the best pictures possible.
PET-CT Prep Sheet for Brain Imaging PET-CT Bone Instructions	This prep ensures that we obtain the best pictures possible for patients who have a PET-CT of the brain. Instructions are applicable twelve (12) hours before your appointment. 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 one page PDF that you can download and print includes helpful information on what to expect during an ultrasound-guided thyroid biopsy.
MRI-Guided Breast Biopsy Instructions Stereo-Guided Breast Biopsy Instructions Ultrasound-Guided Breast Biopsy Instructions Ductogram Instructions	This two page PDF that you can download and print includes helpful information on what to expect during the MRI guided procedure. This two page PDF that you can download and print includes helpful information on what to expect during the stereo guided procedure. This two page PDF that you can download and print includes helpful information on what to expect during the ultrasound guided procedure. This PDF file that you can download and print includes helpful information on what to expect during a ductogram procedure.

http://www.provimaging.com/Default.aspx?app=LeadgenDownload&shortpath=docs%2fFinancial-Assistance-Form.pdf

Brochures

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.
PET-CT patient brochure	Learn what makes integrated PET-CT superior to stand alone PET scanners, and what to expect.

Screening Forms

MRI Screening Form

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

Order forms/requisitions

PIC Order Form

This is our current requisition form last revised 4/09, the familiar two sided one with the PIC people in the upper left hand corner.

PET-CT Order Form

PET-CT Bone 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.

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 originally released July 2007 is ideal for requesting an MRI of the breast, and includes all breast imaging offered at PIC.

Directions with appointment card/map

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

General information/reference cards

Clinician Information Card	This one-sided reference card provides clinicians and staff with general information about PIC 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.
How-to-Schedule information sheet for mammography	This handy two-sided reference card provides helpful information on correctly scheduling mammography and other breast imaging
PET-CT Medicare Reimbursement Guide	This handy two-sided reference card provides helpful information on which PET exams are covered by Medicare as of 2008

Financial Assistance

Charity Care Financial Assistance Form
Providence Imaging Center does participate 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. After completing the form, please fax it to (907) 212-5827 or drop it off at our front desk at 3340 Providence Drive, Anchorage, AK 99508.