Request IHS Assistance - Imaging Healthcare Specialists

Physician/Provider Request *
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URGENT: PATIENT WAITING
URGENT: PHYSICIAN REQUIRES ASSISTANCE

Physician Last Name*

Physician First Name*

Suffix *

Specialty *

Official Group/Practice Name*

Street Address *

Suite

City*

State *

Zip *

Phone +Ext.*

Fax*

Physician/Provider Email*
Enter Email

MyIHS User Name*

Assistance Required: * (Choose all that Apply)

Request Portal Access (MA/Staff)
Request Referral Pads
(Will be mailed next business day)
Request ICA Access –
Providers Only Access
Other – Explain Reason:

Patient Last Name

Patient First Name

Patient Date of Birth

Contact Information +Ext.*

Enter FULL Name – Office Contact*

Request Submitted By *

Title *

Request for IHS Assistance

Enter Physician/Provider Information
*All fields are required

Patient Information

Caller Contact Information *All fields are required

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Email

Fax

IMAGING HEALTHCARE SPECIALISTS