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Imaging Resources
Main Content
External Image Upload Request
All outside images for patient care require the following information to be submitted with the images.
*
= Required Fields
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
*
(
)
-
ext.
Person completing this form
*
Contact number or pager
*
(
)
-
ext.
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