Care Navigation Form

  • Care Navigation Form

    Please fill out the information below so that we can help you find a Provider.

  • Introduction:

    At America's HealthShare, we believe our Members have the right to direct their own healthcare. You have the ability to see any healthcare provider of your choosing. Care Navigation services are intended to help you locate the best provider option for your specific situation. If you need help locating a provider, please fill out the information below and our Care Navigation Team will contact you about provider options.

    Please note that every effort is made to ensure the accuracy of the information provided, but we cannot guarantee all information will be current. We appreciate feedback to help us provide the most accurate information possible to help serve our Membership. 

    If you would like to nominate any of your providers to try and expand our Preferred Provider relationships, please fill out a Provider Nomination form.

  • Is this request related to a non-imaging service for upcoming surgery, cancer, or maternity services?*

  • Please note: If this request is being submitted related to an upcoming surgery, current cancer treatment or maternity services, this request needs to go through our Care Coordination team. Please fill out the Inquiry Form here.


  • Format: (000) 000-0000.

  • Navigation Information Needed

  • How to search for Navigation Options
  • Are you open to telehealth counseling options?
  • Would you like to select another specialty for navigation options?*
  • Are you open to telehealth counseling options?
  • Would you like to select another specialty for navigation options?*
  • Are you open to telehealth counseling options?

  • Imaging

  • Please note that a referral/order is needed to obtain your imaging. If you do not have a referral/order, please contact your physician.

    We have many scheduling partners who provide exceptional services at fair and just costs for America's HealthShare Members.

    Please fill out the information below to help us get you scheduled for your imaging!

  • Is your upcoming service related to an MRI or Nuclear Imaging (PET Scan, Bone Scan, etc...)?*
  • If yes, do you have an approved Pre-Notification on file?*

  • If your upcoming service is an MRI or Nuclear Imaging, these imaging services require an approved Pre-Notification. It is advised to have your physician fill out a Pre-Notification form on your behalf. To obtain the Pre-Notification form, please click here.

  • Low Dose Cancer Screening

    A procedure that uses a computer linked to an x-ray machine that gives off a very low dose of radiation to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create 3-D views of tissues and organs. Low-dose CT scan is recommended as a screening test for adults who have a high risk of developing lung cancer based on their age and smoking history.
  • Do you have a history of Lung Cancer?*
  • Do you have any signs or symptoms of lung cancer, such as unexplained cough, hemoptysis (coughing up blood), or unexplained weight loss of more than 15 lbs in a year?*
  • Do you currently smoke?*
  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need special accommodation?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
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  • Mammogram Screening

    A screening mammogram is a low-dose imaging test that helps doctors spot changes in breast tissue.
  • Do you have any breast implants?*
  • Do you have any concerns about your breasts, such as pain, lumps, bumps, skin rashes, or discharge from from the breast?*
  • Do you have a family history of breast cancer?*
  • Are any of these relatives on your mother's side of the family?*
  • Have you had a mammogram before?*
  • If yes, when was your last mammogram?*
     - -
  • Do you have your prior mammography images and reports?*
  • Are you currently pregnant?*
  • Are you currently breastfeeding?*
  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
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  • CT Screening

    CT screening is a noninvasive imaging procedure that uses X-rays to create detailed pictures of the body to help detect disease or injury.
  • Are you currently pregnant?*
  • Have you had any prior surgery to the area about to be scanned?*
  • Do you have a history of cancer or dialysis?*
  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
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  • Breast MRI Screening

  • Do you have any breast implants?*
  • Do you have any concerns about your breasts, such as pain, lumps, bumps, skin rashes, or discharge coming from the breast?*
  • Do you have a family history of breast cancer?*
  • Are any of these relatives on your mother's side of the family?*
  • Have you had a mammogram before?*
  • If yes, when was your last mammogram?*
     - -
  • Do you have your prior mammography images and reports?*
  • Are you a female?*
  • Are you currently pregnant?*
  • Are you currently breastfeeding?*
  • Are you still menstruating?*
  • If yes, what was the first day of your last menstrual cycle?*
     - -
  • Have you had any prior surgery to the area about to be scanned?*
  • Do you have any metal in your body?*
  • Do you have a post-surgical card with a serial number?*
  • Have you performed work involving cutting or grinding metal?*
  • Do you have implanted devices, such as a pacemaker, pain pump, glucose monitor, or aneurysm clips?*
  • If yes, do you have the card for that device?*
  • Are you claustrophobic?*
  • Have you had any prior imaging to this area of the body?*
  • Are you able to lay flat for at least 30 minutes?*
  • Do you have a history of cancer or dialysis?*
  • Do you have any of the following conditions: Diabetes, Kidney Disease, Liver Disease, or High Blood Pressure?*
  • Are you over the age of 50?*
  • Have you had bloodwork done in the past 30 days?*

  • If yes, please send a copy of your bloodwork results or provide the name and phone number of the doctor who ordered the bloodwork and Green Imaging will request it on your behalf.

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  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
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  • MR Contrast Exams

    MR stands for magnetic resonance, and there are multiple types of MR imaging techniques, including MRI, MRA, and MRS.
  • Have you had any prior surgery to the area about to be scanned?*
  • Do you have metal in your body?*
  • Do you have a post-surgical card with a serial number?*
  • Have you performed work involving cutting or grinding metal?*
  • Do you have implanted devices, such as a pacemaker, pain pump, glucose monitor, or aneurysm clips?*
  • If yes, do you have the card for that device?*
  • Are you claustrophobic?*
  • Are you currently pregnant?*
  • Have you had any prior imaging to this area of the body?*
  • Are you able to lay flat for at least 30 minutes?*
  • Do you have a history of cancer or dialysis?*
  • Do you have any of the following conditions: Diabetes, Kidney Disease, Liver Disease, or High Blood Pressure?*
  • Are you over the age of 50?*
  • If yes, have you had bloodwork done in the past 30 days?*

  • If yes, please send a copy of your bloodwork results, or provide the name and phone number of the doctor who ordered the bloodwork, and Green Imaging will request it on your behalf.

  • Browse Files
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  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
  • Browse Files
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  • MRI Screening

    Also known as a non-contrast MRI, this type of scan doesn't use a dye and can still produce detailed images. Non-contrast MRIs are often used for orthopedic studies and to detect aneurysms and blocked blood vessels.
  • Have you had any prior surgery to the area about to be scanned?*
  • Do you have any metal in your body?*
  • Do you have a post-surgical card with a serial number?*
  • Have you performed work involving cutting or grinding metal?*
  • Do you have implanted devices, such as a pacemaker, pain pump, glucose monitor, or aneurysm clips?*
  • If yes, do you have the card for that device?*
  • Are you claustrophobic?*
  • Do you have any of the following conditions: Diabetes, Kidney Disease, Liver Disease, or High Blood Pressure?*
  • If yes, have you had bloodwork done in the last 30 days?*

  • If yes, please send a copy of your bloodwork results or provide the name and phone number of the doctor who ordered the bloodwork and Green Imaging will request it on your behalf.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Are you currently pregnant?*
  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
  • Browse Files
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  • CT/IVP Contrast Exam

    A CT/IVP (computed tomography intravenous pyelogram) is a diagnostic exam that combines a CT scan with an intravenous pyelogram (IVP) to examine the urinary tract.
  • Have you ever had a reaction to CT contrast?*
  • When was the reaction?*
     - -
  • Are you currently pregnant?*
  • Have you had any prior surgery to the area about to be scanned?*
  • Do you have a history of cancer or dialysis?*
  • Do you have any of the following conditions: Diabetes, Kidney Disease, Liver Disease, High Blood Pressure?*
  • If yes, have you had routine bloodwork done in the last 30 days?*

  • If yes, please attach a copy of your bloodwork results or provide the name and phone number of the doctor who ordered the bloodwork and Green Imaging will request it on your behalf.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
  • Browse Files
    Drag and drop files here
    Choose a file
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  • Imaging

    All other imaging services may include: Ultrasounds, EKG, Bone Scan, Stress Test, etc...
  • Do you have any allergies?*
  • If yes, please select.*
  • Do you need any special accommodations?*
  • Date of Service Preference (1)*
     - -
  • Date of Service Preference (2)
     - -
  • Date of Service Preference (3)
     - -
  • Do you prefer mornings or afternoons?*
  • Browse Files
    Drag and drop files here
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    Cancelof

  • Review Your Care Navigation Information

  • Please review the information you entered before submitting your form

     

    Membership ID Number: {MembershipID}

    Member Name: {MemberName}

    Member Email: {MemberEmail}

    Member Phone: {contactNumber}

    Navigation Search Area: {CityState} {Zip}

    Specialty: {Specialty1}   {Specialty2}   {Specialty3}

    Description of Service: {Description}

  • Other Specialty: {ifother1} {ifother2} {ifother3}

     

     

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