CHCFC - Dental X-Ray Transfer Request

1. Patient Identification

Patient MRN (Medical Record Number)*

Must be exactly 7 digits with no letters.

2. Transfer Locations

Current X-Ray Location*

Orange

Greenfield

Baystate

Location Needing Transferred To (Select one or more)*

Orange

Greenfield

Baystate

3. Schedule & Timing

Dates Needed (Dates X-Rays Were Taken in Past)*

From Date (Past)

To Date (Past)

Select the past date range during which the original X-Rays were taken.

Date Needed By (Target Transfer Date)*

Future date the transfer must be completed by (before patient appointment).

⚠️ Urgent Notice: Less Than 48 Hours

I understand that best effort will be provided to transfer the X-Rays by the selected date, and that all X-Rays should be put in at least 48 hours before.

4. Submitter Information

Your Name*

Your Email*

Phone extension if clarification is needed

Extension where staff can reach you if questions arise.

Additional Details / Teeth Numbers (Optional)

Please do not include any PHI in this field.

✓

Request Submitted Successfully!

A help desk ticket has been generated in NinjaOne.

Ticket #0000

MRN:

Route:

Dates Needed:

Needed By:

Requester: