Rutland Form 2772 PDF Details

Are you looking to fill out the Rutland Form 2772 for health insurance claims? It can be a confusing process if you don't understand how it works, but there's no need to worry. In this blog post, we'll explain the ins and outs of what is involved in completing the Rutland Form 2772. We'll cover everything from who should submit a claim using this form to when and why they would do so. Additionally, we'll provide some helpful tips that can make filling out your Forms 2772 as simple as possible! So whether you're brand-new to dealing with health insurance claims or an experienced professional, keep reading to learn more about the vital role that Form 2772 plays in submitting claims.

Form NameRutland Form 2772
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other names183MRI_Order Prescreening_Qu estionnaire_277 2 mri fill in the blanks form

Form Preview Example

Outpatient MRI Order/ Prescreening Questionnaire

Upon completion, please fax to central scheduling at 776-3301.

(For Breast MRI only, fax to Breast Care Program at 747-6595.)

Patient Name: ____________________________________

Date of Birth: _______________________________

Patient Phone (8am-4pm) ___________________________

Referring Physician: _________________________

Can we leave a message? Yes No

Physician Signature: ________________________

(If not, please have patient call us the next business day 747-1707.)

Date and Time: ____________________________

77002 Fluoroscopy for needle placement for MR arthrogram injection

MR Arthrogram ___________

Type of MRI ordered: ________________________________ IV contrast with

without with and without

Diagnosis/What are we looking for? _______________________________________________________________

Symptomatology/Findings: ______________________________________________________________________


Does patient have a pacemaker (or pacemaker wires in chest), implantable cardiovascular device (ICD) or external device (insulin pump)?

Does patient have a brain aneurysm clip? If yes, call MRI at 747-1707 before scheduling.

Does patient have fear of close places (claustrophobia)? If yes, physician to specify minimal

or moderate sedation?

minimal (anxiolysis)


Is patient 60 years of age?

Yes No

Patient weight: __________

Is patient diabetic? Yes


Patient height: __________

If the patient is diabetic or over 60years of age a BUN and Creatinine is required (within 90 days) if patient is receiving contrast.

BUN_________ CREATININE_______ DATE________

Has patient ever had eye surgery that resulted in implants other than cataract lens?

If yes, what/when? ___________________________________________________________

Has patient ever had ear surgery that resulted in a metal cochlear implant? If yes, call MRI with type of implant. ___________________________________________

Has patient ever had an accident with metal in the eye? If yes, have they had an MRI since? If not, patient must have an x-ray before the MRI (can be done 1-2 days prior or before 5 pm on day of exam).

Has patient had any recent prior surgery, as MRIs should be done 4-8 weeks after most surgery? (If patient has had a coronary stent or Greenfield filter put in, scan must be 6 weeks postop.) Date/type of recent prior surgery: _______________________________________

Does patient have any implanted devices (other than cataract lenses)?

If yes, what? _______________________________________________________________

Is patient pregnant or think she may be pregnant? Yes No Is patient a nursing mother? Yes No

Does patient have difficulty lying flat on his/her back or stomach? If so, which?___________


Is patient on hormone replacement therapy (HRT)? If yes, patient needs to be off HRT for 6 weeks before MRI is performed. Date of last dose: ______________________

First day of last menstrual period: ____________ Date next period expected: ____________

MRI must be at least 6 months after end of radiation treatment; at least 1 year after end of chemotherapy.

Above portion completed by_____________________________ Date/Time _________________________


MRUN: _____________ Booked by: _________ Date/Time: ________________ Confirmation #: __________

Other Exams: ___________________________________ MRI scheduled for:__________________________

FORM # 2772 REV. 03/08; 05/08, 09/08, 12/08, 5/09