URPrecious Imaging Referral Provider Portal Access Request Form

URPrecious Imaging Referral Provider Portal Access Request Form

Please complete the following form to provide referral details and contact information.
Referral Information

Enter the details of the referring provider below. Completing this form does not automatically create an account. URPrecious Imaging PACS administrator will verify your information and contact you once your account is activated.
Full Name*

First NameMiddle NameLast Name
Credentials*
NPI
Speciality*
Practice Name*
Practice Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Information

Provide contact details for follow-up.
Office Phone Number*
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Email Address*
example@example.com
Distribution Preferences

Select all applicable methods for receiving information.
Preferred Report Receiving Methods*

FaxEmail (HIPAA secure)
Please verify that you are human*
Should be Empty: