Study Request FormFor ProvidersThis form is for healthcare providers only.Providers, we will deliver your requested studies via PowerShare within one business day. If you would prefer to fax a request, you may send it to 317-715-9984. You must have JavaScript enabled to use this form. Requester Please provide your first and last name. Phone # Please provide your phone number. We will only contact you if we have a question. PowerShare Contact Please provide the PowerShare name/address where you would like the studies sent. Patient Name Please provide the patient's first and last name. Patient Date of Birth Studies Requested Please include the type of exam and date the study was done. You may request multiple (all CT studies of the HEAD from 2015) or (Head CT from 2012 and Chest CT from 2020).
