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Appointment Request Form
for Breast Center


Please use the form below to request an appointment at Valley Hospital's Diagnostic Imaging Department or Breast Center. A physician's prescription is needed for all tests at Valley Hospital and you will need to bring it with you. All fields with a red asterisk are mandatory and must be completed to submit your request. This form will be sent to a Diagnostic Imaging Registrar at Valley Hospital who will call you back within one business day to confirm a date and time with you. Our Registrars receive Internet inquiries and will place phone calls between 8:30 a.m. and 4:30 p.m., Monday through Friday.

Valley considers the information you provide as confidential and it will not be shared with any third parties. All submissions will receive an automatic e-mail informing you that we have received your information.

Please contact your doctor if you have any questions about the prescription for your test. Some procedures require pre-authorization from your insurer. Please check with your insurance company.

If you would prefer to make an appointment by telephone, please call us at 201-447-8422.

Thank you for choosing The Valley Hospital.

* To move from one field to the next in this form, please use the Tab key.


Patient Name*:
Patient Gender*:
Patient Date of Birth*:
Address1:
City:
State:
Zip:
Email Address*:
Day Phone*: Ext
Evening Phone*: Ext
Ordering Physician:
I am:

Has the patient been treated
at Valley Hospital for anything
in the past?
   
Upload Your Scanned Prescription:
   
You may scan your Prescription and upload it here along with your appointment request. Please note that the scan must be saved as a JPG or GIF. If you do not wish to upload your scanned Prescription at this time, we will gather the necessary information when we call you to schedule the appointment.

Name*:
Contact Phone*: Ext
Best Time to Call (Please note: The Breast Center places calls between 8 a.m. and 4:30 p.m.)*:


 

Below are the insurance companies that have contracts with Valley. Please select one Insurer or PPO Network from this list. If your insurance company is not on this list, then it may not have a contract with Valley and your procedure may not be covered. If your insurance provider is not listed, please call us to verify whether you are covered. If you are not covered, you can still have your procedure performed at Valley, but you will need to pay the full amount by cash, check or credit card (Visa or Mastercard).

Please check with your insurance company to determine if pre-authorization is needed. If it is, please make sure you bring the authorization number with you at the time of your test. Patients who fail to secure appropriate authorization will be billed for any payments that are denied.

Please note that our physicians (Radiology Associates of Ridgewood) contract independently with insurers, and they may not accept all the plans the hospital does.
Please click here to view the list of insurers they honor.

Please be aware that some insurance plans may require you to use certain free standing diagnostic imaging facilities or require you to pay more if you receive your service in a hospital setting. You should always check directly with your plan regarding your specific benefits before seeking services.
Insurers:
 
PPO Networks:

Please enter the name(s) of the test(s)/procedure(s) you would like to make an appointment for. The name of the test is written on the prescription your physician gave you. If you are unsure what procedure you need, please contact your physician.
(1)
Type of Exam*:
Please state purpose of exam or diagnosis:
Enter insurance authorization number or name (if applicable):
(2)
Type of Exam:
Please state purpose of exam or diagnosis:
Enter insurance authorization number or name (if applicable):
(3)
Type of Exam:
Please state purpose of exam or diagnosis:
Enter insurance authorization number or name (if applicable):
(4)
Type of Exam:
Please state purpose of exam or diagnosis:
Enter insurance authorization number or name (if applicable):

Please indicate the day and time you would like to schedule your appointment. This information will expedite the process when our Registrar calls you.

Preferred Day for Appointment:

First Choice:
Second Choice:

Preferred Approximate Time for Appointment

(We will identify a specific time when we call you.)
First Preference (Time):

Second Preference (Time):

Thank you for completing the form. To proceed, please click on 'Review Information,' where you will preview the information before sending it. If you wish to clear the entire form and start again, click 'Reset'.

Mailing Address:
The Valley Hospital
223 N. Van Dien Avenue
Ridgewood, NJ 07450
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