Referring Physician Offices

Medical Imaging has created a single referral form for Rhode Island and The Miriam hospitals to make ordering quick and easy. Please contact us for more information.

Referral Forms

• Outpatient referral form: Fax form to 401-444-7779
  • Download referral for exams requiring pre-authorization (CT, MRI)
• PET /CT Order Sheet  
  (Fax form to 401-444-4447)
• Cardiovascular MR Exam Referral Form  
  (Fax numbers for Rhode Island and The Miriam hospitals indicated on form)
• Breast MRI Request Form  
  (Fax form to 401-444-5732)
• Nuclear Medicine Order Sheet  
  (Fax numbers for Rhode Island and The Miriam hospitals indicated on form)
• Pediatric Referral Form  
  (Fax number indicated on form)
• Secure online outpatient referral form
  Requires Lifespan login; call 401-444-7770
  for more information.

Newport Hospital

• Newport Hospital referral form  
  (Fax numbers indicated on form, please do not fax to business center) 
• Interventional Radiology Patient Referral Form   

Contact Information

• Have a question on a specific modality? Contact a Radiologist.

• For billing questions, call 401-444-7771 or email imaging@lifespan.org.