RAPC Request For An Addendum or Review

This form is to be submitted only by facilities that generated the imaging study.
If you are a referring physician please contact the facility that generated the study to request changes to the result.

Imaging Facility:
Requestor: (Your Name)
Email
Physician/Provider requesting correction:
Requestor Phone: Requestor Phone: - ### - ### ####
Patient/Study information
Patient Name Patient Name First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
RAPC Accession Number:
Date of Service: Date of Service: / MM / DD YYYY
Exam Description:
Summary of Change Request:
By signing this form, the [PERFORMING FACILITY REFERENCED ABOVE] representative requests RAPC to make the requested changes in the patient record. The [PERFORMING FACILITY REFERENCED ABOVE] is solely responsible for the accuracy of the information on this form. The [PERFORMING FACILITY REFERENCED ABOVE] further acknowledges that the requested changes are being made solely at the request of the [PERFORMING FACILITY REFERENCED ABOVE]. In addition, the [PERFORMING FACILITY REFERENCED ABOVE] is solely responsible for any additional communication to affected parties as the result of the request, to include and not limited to the patient, providers, or payers.

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Full Name
Requestor Name: Requestor Name: First Last
Date Date / MM / DD YYYY

RAPC Request For An Addendum or Review

RAPC Request For An Addendum or Review

Patient/Study information