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Precertification Request Form

Larchmont Imaging is happy to introduce our Insurance Precertification Request service. 

Many insurance providers ask Larchmont Imaging to obtain precertification (pre-cert) forms on behalf of our patients that have been referred to us. To begin a precertification request, please fax the following information to Larchmont Imaging at (877) 211-9603. 


  • Order/Referral/Prescription for the requested study
  • Completed Precertification Request Form
  • Any applicable notes to support the Precertification Request


Larchmont will reach out to the correct Radiology Benefits Management Program (RBM) for the patient's insurance carrier using the above information. Once the precertification is approved, we will contact the patient to schedule the study. If the precertification is denied or pending, we will notify you immediately so you can provide additional information or appeal the denial with the insurance carrier. 

Unfornuately, Larchmont Imaging cannot obtain precertification for No-Fault (MVA), Workers Compensation, or non-participating insurance carriers.

If you have any questions or concerns regarding Larchmont's precertification services, reach out to our Precertification Coordinator at (609) 261-4500 ext 1997.   


Larchmont Precertification Request Form

Patient Compliments

Love coming to the Medford Office.  Quality and efficient service.  No long wait time.

I have used Larchmont over the years.  Everyone is kind and helpful, making many appointments for my mother to accommodate my schedule.  Thank you-everyone is great!


I go back and forth between NJ and FL.  I always wait until I'm in NJ for imaging so I can come to Larchmont.

Larchmont client for many years (Sunset Rd., Willingboro)-always very satisfied with staff.


This team is so amazing!  Everyone was so kind and I was in and out in no time!


Entire staff was very knowledgeable and professional.  Every aspect of my test experience was pleasant.