The Queen’s imaging testing form, formally the Imaging Outpatient Testing Form, is the order document your physician completes to request a CT, MRI, ultrasound, PET, or similar diagnostic exam at a Queen’s facility. Your physician’s office downloads it from the Queen’s Health Systems imaging resources page for providers, fills in the clinical details, and either faxes it to 808-691-7007 or submits the order electronically through their health record system.1The Queen’s Health Systems. Resources For Imaging Physicians You don’t complete the clinical sections yourself, but what the form says about you drives whether your scan gets authorized, scheduled, and billed correctly, so it pays to know how it moves.
Who Fills Out the Form
The ordering physician does. The form lives on the imaging services physician resources page at Queen’s Health Systems, and only providers download and submit it.1The Queen’s Health Systems. Resources For Imaging Physicians If your doctor’s office uses an electronic ordering system, there may be no paper form at all; the electronic order serves the same purpose.
Queen’s North Hawai’i Community Hospital uses its own Imaging Service Form and a separate Mammography Service Form, downloadable from that facility’s imaging page.2The Queen’s Health Systems. Imaging at Queen’s North Hawai’i Community Hospital If there’s any doubt about which form applies, your physician’s office can call Queen’s scheduling at 808-691-7171 to confirm before sending anything.
What the Form Contains
Two kinds of information: who you are and what’s being ordered. Errors in either part delay scheduling and can trigger insurance denials, so the few minutes it takes to verify the details are worth it.
Your Identifiers
The form captures your full legal name, date of birth, and current contact information. Your doctor’s office pulls this from their records, but confirm it matches your insurance card exactly. A misspelled name or a transposed digit creates billing problems that can take weeks to unwind.
The Clinical Order
Your physician enters the imaging modality, the body part to be examined, relevant clinical history, and an ICD-10 diagnosis code. ICD-10 is the standardized coding system used across U.S. healthcare to link your diagnosis or symptoms to the services ordered.3Centers for Medicare & Medicaid Services. ICD-10 Insurers use that code to decide whether the exam is medically necessary, and a vague or wrong code is one of the most common reasons prior authorizations get denied.
The ordering provider also signs the form. Medicare and other insurers can deny claims when an imaging order lacks a signature, evidence of the physician’s intent to order the test, or documentation of medical necessity.4Centers for Medicare & Medicaid Services. Complying with Signature Requirements for Diagnostic Tests If the signature is illegible, providers can submit a signature log or attestation statement to verify the ordering physician’s identity.
How the Order Gets to Queen’s
Two paths. Electronic submission flows directly into Queen’s scheduling system and cuts the risk of transcription errors. Faxing the completed form to 808-691-7007 produces a confirmation report that acts as proof of delivery if a dispute ever comes up about whether the order was received.1The Queen’s Health Systems. Resources For Imaging Physicians
Providers can also call Queen’s Patient Service Coordinators at 808-691-7171 to work directly with staff who specialize in scheduling specific imaging modalities, which helps for complex exams with equipment or prep requirements.1The Queen’s Health Systems. Resources For Imaging Physicians A quick follow-up call to that same number after submission confirms the department received everything and can start the insurance review.
All transmission of patient health information, whether by fax or electronic system, must comply with HIPAA’s Security Rule, which requires technical safeguards against unauthorized access to electronic protected health information during transmission.5U.S. Department of Health and Human Services. Summary of the HIPAA Security Rule
What Happens After the Form Is Submitted
Queen’s imaging staff review the order for completeness and begin prior authorization with your insurer if your plan requires it. Standard authorization reviews can take up to 30 days; urgent requests typically get a response within 72 hours. The order form itself triggers the authorization, so any missing field or mismatched diagnosis code stalls the process before it starts.
Once authorization is in place, Queen’s contacts you to schedule. You can also reach the scheduling team directly at 808-691-7171, and pre-registration runs through 808-691-4960.1The Queen’s Health Systems. Resources For Imaging Physicians Pre-registering lets staff verify insurance, collect demographics, and confirm the exam details before your visit, which shortens your wait on the day of the scan.
Safety Screening You’ll Complete Yourself
The order form schedules the exam, but a separate safety screening happens before certain scans, especially MRIs. This is a patient-safety step and applies every time, even if you’ve had the same scan before.
MRI Screening
Before an MRI, you’ll complete a questionnaire about implanted devices, metallic foreign bodies, and pregnancy status. Every question must be answered, and any “yes” response needs more detail. Staff verify the exact make, model, and location of any implant using operative notes or device identification cards.6Image Wisely. Basics of MRI Patient Screening If you have a pacemaker, cochlear implant, neurostimulator, aneurysm clip, or any history of metal fragments from an injury, bring documentation or expect additional evaluation before the scan.
Non-emergency patients go through at least two rounds of screening: once when the exam is ordered, and again on arrival. You’ll change into a gown and remove jewelry, watches, hearing aids, piercings, and hair pins. Patients who can’t give their own history, because of age, altered consciousness, or cognitive impairment, need a family member or guardian to complete the questionnaire for them.6Image Wisely. Basics of MRI Patient Screening
Contrast Dye
Some CT scans and MRIs use contrast dye. If you have a known allergy to iodine-based contrast, your referring physician should flag it on the order form so the imaging team can plan. Premedication for patients with a documented contrast allergy typically involves oral steroids and an antihistamine taken in the hours before the exam, and you’ll need someone to drive you home afterward. Tell your doctor about any past contrast reaction when the order is first placed, not at the appointment, so the team has time to prepare.
Which Queen’s Location Will Do the Scan
The Queen’s Medical Center’s main imaging department is at 1301 Punchbowl Street, Honolulu, Hawai’i 96813, on Level 1 via the Queen Emma Elevator. The network also includes The Queen’s Medical Center – West O’ahu, The Queen’s Medical Center – Wahiawā, Queen’s North Hawai’i Community Hospital, and Molokai General Hospital.7The Queen’s Health Systems. The Queen’s Health Systems Not every site offers every modality; PET imaging, for instance, is housed at the Hamamatsu/Queen’s PET Imaging Center on the main Queen’s Medical Center campus.8The Queen’s Health Systems. Imaging Services When you schedule, confirm the location has the right equipment for your exam. The scheduling coordinators at 808-691-7171 can route you.
What You Can Expect to Pay
Costs run from relatively inexpensive X-rays to high-dollar MRIs and PET scans, and what you owe depends on your plan. Medicare Part B beneficiaries face a $283 annual deductible in 2026, and after that most outpatient diagnostic imaging is subject to 20 percent coinsurance.9Centers for Medicare & Medicaid Services. 2026 Medicare Parts A & B Premiums and Deductibles Private plan cost-sharing varies.
If you’re uninsured or paying out of pocket, federal law gives you the right to a good faith estimate of expected charges before the appointment. Under the No Surprises Act, the facility must provide a written estimate within one business day of scheduling if the appointment is at least three business days away, or within three business days if it’s further out. If the final bill substantially exceeds the estimate, you can dispute the charges through a patient-provider dispute resolution process.10eCFR. 45 CFR 149.610 – Requirements for Provision of Good Faith Estimates Ask for the estimate in writing when you schedule.
If the Insurer Denies the Order
Denials usually come down to one of three things: the diagnosis code on the form didn’t meet the insurer’s medical-necessity criteria, prior authorization wasn’t obtained before the exam, or the insurer considers a cheaper modality sufficient. Start by asking the insurer for a written explanation that includes the specific denial reason and code.
Have your physician’s office verify the billing and diagnosis codes. Coding errors are common and fixable, and a corrected resubmission sometimes resolves it without a formal appeal. If the codes were right and the denial stands, your doctor can request a peer-to-peer review, a direct conversation with the insurer’s medical reviewer about why the test is needed.
Most private plans regulated under the Affordable Care Act must offer a two-level appeals process: an internal appeal with the insurer, followed by independent external review if the internal appeal fails. You typically have 60 to 180 days from the denial date to file internally, depending on the plan. If you need the imaging urgently, an expedited appeal can be resolved within 72 hours. Medicare beneficiaries have a similar right to appeal within 60 days and can escalate through multiple levels. Keep copies of every letter and document every phone call, including dates, names, and what was said; appeals without a paper trail tend to go nowhere.
Getting Your Results
Queen’s uses MyChart as its patient portal. Once your exam is complete, you can view results securely through MyChart along with other medical records. The portal also lets you schedule appointments, request refills, message your provider, pay bills, and access video visits.11The Queen’s Health Systems. Queen’s MyChart Parents can manage a child’s care through the portal, and teens aged 14 to 17 have limited independent access to make appointments and view certain records.
Imaging results often need interpretation by a radiologist before they appear in MyChart, and your ordering physician receives the radiologist’s report and typically discusses the findings with you. If results show up in the portal and you have questions, message your provider or call the office rather than trying to read the report on your own.